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HX00044008 


intljeCffpofUmigork 

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LIBRARY  OF 

Dr.  carl  F.  W.  BODECKER 

1846-1912 

The  gift  of 

Dr.  i-fcD'-y  and  Dr.  Charles  Bodecker 

1929 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/orthodontiaorthoOOjack 


ORTHODONTIA 


AND 


Orthop/edia  of  the  Face 


BY 

VICTOR  HUGO  JACKSON.  M.D.,  D.D.S. 

MEMBER     OF    THE    NATIONAL    DENTAL    ASSOCIATION  ;     PROFESSOR    OF    ORTHODONTIA    IN 

THE     DENTAL     DEPARTMENT    OF    THE     UNIVERSITY    OF    BUFFALO  ;     FELLOW 

OF    THE    NEW     YORK    ACADEMY    OF    MEDICINE  ;     MEMBER     OF 

THE    AMERICAN     MEDICAL     ASSOCIATION,     ETC. 


WITH  SEVEN   HUNDRED  AND  SIXTY  ORIGINAL 
ILLUSTFIATIONS 


PHILADELPHIA  AND   LONDON 

J.  B.  LIPPINCOTT    COMPANY 

1904 


Copyright,  1904 

BY 

Victor   Hugo  Jackson 

All  rir/hta  reserved 


ELECTBOTYPEO    AND    PHINTtO    BY    J.    B.    LJPPINCOTT    COMPANY,     PHILADELPHIA,     U.B.  A. 


TO   MY    BROTHERS 
DR.  HARRY  HAMILTON  JACKSON 

AXD 

DR.  WALTER  HINCKLEY  JACKSON 

THIS  VOLUME  IS 
AFFECTIONATELY  INSCRIBED 


PREFACE 

In  writing  this  book  it  has  been  my  purpose  to  present,  in  detail, 
yet  in  a  concise  and  systematic  form,  a  description  of  my  methods 
of  correcting  irregularities  of  the  teeth,  and  also  to  introduce  a  com- 
plete and  original  system  for  the  orthopaedic  treatment  of  the  face. 
I  have  aimed  to  treat  the  subject  in  such  a  manner  as  both  to  adapt 
it  as  a  text-book  for  the  student  and  to  suggest  methods  of  procedure 
for  the  active  practitioner. 

In  1887  I  presented  a  simple  wire  device  for  the  regulation  of 
teeth  which  I  termed  a  Crib.*  The  anchorage  was  gained  by 
extending  a  spring-wire  on  the  lingual  and  labial  sides  of  the  teeth 
near  the  gum,  in  some  cases  including  all  of  the  teeth,  in  others  only 
a  part  of  those  in  the  arch  ;  the  spring  on  the  labial  and  lingual  sides 
was  connected  by  passing  wires  over  the  arch  at  the  junction  of  the 
teeth.  Later  I  devised  the  Jackson  system  described.  The  anchor- 
age is  secured  by  spring-clasp  attachments  and  partial-clasps,  sup- 
porting a  base-wire,  to  which  any  form  of  spring  can  be  added. 

The  introduction  of  a  new  system  necessitates  new  names,  but  an 
effort  has  been  made  to  use  those  that  will  be  readily  understood, 
avoiding  overfull  descriptions  and  unnecessary  technical  terms. 

In  some  of  the  chapters  descriptions  of  a  few  well-known  methods 
that  have  been  used  successfully  by  the  profession  are  included. 
These  are  presented  in  order  to  assist  practitioners  who  are  using 
those  methods  and  who  are  not  yet  familiar  with  the  system  of 
anchorage  advocated  in  this  work.  The  book  contains  four  hundred 
and  fifty  pages  of  text,  thirty-four  insets,  and  an  appendix  including 
descriptive  matter  and  forty-four  page  plates  illustrating  apparatus 
that  has  been  used.  There  are  in  all  eight  hundred  and  one  cuts, 
seven  hundred  and  sixty  of  which  are  original  with  me. 

Orthodontia  has  grown  in  importance  until  it  has  become  a 
specialty  of  dentistry.  It  is  engaging  some  of  the  most  active  and 
original  minds  in  the  profession.  Opinions  have  been  recorded, 
theories  advanced  and  contested,  until  the  literature  of  orthodontia 
has  attained  a  volume  proportionate  to  the  importance  of  the  subject. 

*  Jackson,  Dental  Cosmos,  1887,  p.  375. 


6  PREFACE 

For  many  years  I  have  applied  in  my  own  practice  the  principles 
explamed  in  this  book,  and  the  results  warrant  me  in  giving  a 
detailed  description  of  my  system.  In  the  mean  time  I  have  been 
urging  upon  the  profession,  in  writings  and  public  demonstrations, 
the  use  of  the  spring  as  a  force  in  regulating,  and  it  is  especially 
gratifying  to  note  its  more  general  adoption  in  place  of  screw-pressure. 

Evolution  is  the  law  of  our  science  as  of  other  studies.  To  realize 
this,  one  has  but  to  compare  the  methods  of  a  few  years  ago  with 
those  of  to-day.  As  it  stands,  my  system  of  correcting  irregularities 
includes  important  modifications  of  the  appliances  originally  pre- 
sented by  me.  The  changes  are  in  the  line  of  simplicity  and 
practicability. 

In  common  with  others  who  have  devoted  themselves  to  ortho- 
dontia, I  desire  to  express  my  sense  of  obligation  to  the  pioneers  of 
the  profession,  who,  working  under  disadvantages,  have  nevertheless 
done  so  much  for  dentistry  and  for  humanity. 

I  freely  give  the  results  of  my  study  to  the  profession.  Beyond 
the  copyright  of  this  book,  I  reserve  no  exclusive  rights  in  the 
system  to  which  I  have  devoted  years  of  thought  and  labor.  I  need 
not  rehearse  the  perplexities  and  unforeseen  obstacles  which  are  at 
once  the  bane  and  the  fascination  of  scientific  research. 

How  far  I  have  succeeded  in  conquering  the  difficulties  in  my  path 
let  others  judge.  The  story  of  man's  contest  with  the  forces  of  nature 
is  as  old  as  the  world.  No  one  is  more  familiar  with  it  than  mem- 
bers of  our  profession,  who  work  to  relieve  their  fellow-beings  of  the 
consequences  sometimes  of  misfortune,  sometimes  of  folly. 

Although  no  letters  patent  protect  me  in  the  material  advantages 
of  my  system,  I  am  not  without  a  great  reward;  I  shall  find  it  in  the 
knowledge  that  I  have  in  a  manner  aided  the  work  to  which  we 
give  the  best  part  of  our  lives,  the  best  part  of  our  knowledge.  If 
my  professional  brothers  find  the  system  I  have  outlined  a  help  to 
them  in  their  practice,  and  a  step  along  the  road  of  progress,  I  am 
anqjly  repaid. 

I  liave  endeavored  to  give  credit  to  the  authors  for  quotations  and 
the  appliances  to  which  reference  has  been  made.  Acknowledg- 
ments are  due  Dr.  J.  O.  Roe,  the  Dental  Cosmos,  Items  of  Interest, 
the  Internaiioruil  Denial  Journal,  and  their  editors  for  the  use  of  cuts 

and  other  courtesies. 

V.  H.  J. 
New  Yokk. 


CONTENTS 

CHAPTER    I 


Etiology 


Constitutional  and  Local  Causes  of  Irregularity — Heredity — Acquired  Causes 
— Neurotic  Tendencies — Infantile  Scorbutus — Rhachitis — Effects  of 
Muscular  Action — Mouth-Breathing — Enlarged  Tonsils,  Lingual, 
Faucial,  Pharyngeal,  or  Luschka's — Rhinitis — Adenoid  Vegetation — 
Deflection  of  the  Nasal  Septum — Saddle-  and  V-Shaped  Arch — Prog- 
nathism— Unilateral  Prognathism — Hypertrophy  of  the  Tongue — 
Local  Causes  of  Irregularity — Premature  Extraction  of  Deciduous 
Teeth — Unwise  Extraction  of  Permanent  Teeth — Too  Long  Reten- 
tion of  Deciduous  Teeth — Supernumerary  Teeth — Anomalies — Acci- 
dents— Habits  :  Sucking  Thumb,  Fingers,  Lips,  Tongue,  Cheeks — 
Pyorrhoea  Alveolaris 13-52 


CHAPTER    II 
The  Alveolar  Process 

Development — Structure — Function 53-54 


CHAPTER    III 
Occlusion  and  Articulation 

Normal  Occlusion,  Order  and  Arrangement  of  the  Teeth — Abnormal  Occlu- 
sion    55-56 

CHAPTER    IV 

Examination   of   Patients — Record   of   Cases — Impressions — 

Models  of  Teeth — Cast  of  Features 

Diagnosis — Written  Record — Impressions — Impression  of  Chin — Models  : 
To  prepare,  carve,  color,  mount — Measurements,  Wire  and  Card, 
Protilometer,  Facial  Goniometer — Plaster  Cast  of  Features — Photo- 
graph— Skiagraph — Charts 57-67 


8  CONTENTS 

CHAPTER    V 
Age  for  Regulation 

PAOB 

Advantage  of    Early    Correction — Health — Temperament — When    to  delay 

Treatment 68-70 

CHAPTER    VI 
Extraction  of  Teeth  for  Relieving  Irregularities 
Incisors — Cuspids — Bicuspids — Molars 71-75 

CHAPTER    VII 

Anchorage  and  Appliances 

Spring-Clasp  Attachment — Partial-Clasp — Spring-Clasp — Base-Wire,  Rigid 
and  Spring — Forms  of  Base-Wire,  Lingual,  Labio-Buccal,  Palatine  : 
Their  Combination  and  Uses — Teeth  best  suited  for  Anchorage — 
Metal  Caps — Plates — External  Anchorage  —  Cross-Bar  —  Improved 
Cross-Bar — Chin-Cap — External  Supplemental  Anchorage — External 
Independent  Anchorage — Springs,  Size,  Form,  Attachment — Collars 
— Tubes — Lugs — Soldering — Soft  Solder,  Composition  of  ;  Essentials 
for — Flux — Method  of  soldering — Gold  and  Silver  Soldering — Appli- 
ances, finishing,  polishing,  repairing — Action  of  Spring — Advantages 
of  the  Jackson  System — Earlier  Methods  of  regulating 76-116 

CHAPTER    VIII 

Wedging — Application  of  Force — Movements  of  the  Teeth — 
Care  of  the  Teeth  and  Appliances  during  Regulation 

Wedging,  Immediate,  Materials  for — Force,  Constant,  Intermittent,  Vacil- 
lating— Movements  of  the  Teeth — Care  of  Teeth  and  Appliances  .  117-120 

CHAPTER    IX 
Expansion  of  the  Dental  Arch 

Lateral,  Unilateral,  Anterior  Expansion  of  the  Lower  Arch  ;  Upper  Arch  .  121-149 

CHAPTER    X 
Contraction  of  the  Dental  Arch 
Apparatus,   Lower,  Upper — Contraction,  General,  Lateral,  Anterior  .    .  150-165 


CONTENTS  9 

CHAPTER    XI 

Incisors,  to  move  Outward  or  Labially 

PAGK 

Apparatus  to  move  Lower  and  Upper  Incisors  Outward — General,  and  Ex- 
ternal Supplemental  Force — Description  of  Cases — Inclined  Plane — 
Opening  the  Bite — Improving  the  Contour  by  the  Use  of  Crowns — 
Moving  Root  for  Crowning 156-213 

CHAPTER    XII 

Incisors,  to  move  Inward  or  Lingually 

Methods  of  Treatment — Appliances  for  moving  Lower  and  Upper  Incisors 
Inward — Base-Wire  and  Spring-Wire  Devices — Plates — External  Ap- 
paratus, Cross-Bar,  Chin-Cap  and  Wire  Standards,  Supralabial  and 
Infralabial  Bars — Casts  of  Features  before  and  after  Correction — 
Double  Protrusion  or  True  Prognathism — Treatment  of  Thumb- 
Sucking    214-255 

CHAPTER    XIII 

Incisors,  to  move  Laterally 

Closing  Interdental  Spaces — Improving  Occlusion — Encouraging  Eruption — 

Devices — Finger  Pressure — Moving  Bodily — Separating  Teeth  .    .  256-263 

CHAPTER    XIV 

Incisors,  to  Rotate 

Earlier  Methods — Chart  illustrating  Different  Movements — Mesio-lingual, 
Mesio-labial,  Disto-labial,  Disto-lingual  Rotation — Devices — Single 
Rotation— Double  Rotation 264-291 

CHAPTER    XV 

Incisors,  to  Depress — Shaping  the  Teeth 

Thickened  Palatine  Plate — Metal  Caps  passing  over  the  Teeth — Cross-Bar 
Device — Chin-Cap  and  Labial  Bar — Shaping  the  Teeth  to  correct 
Extrusion — Abrasion — To  improve  Occlusion 292-299 

CHAPTER    XVI 
Incisors,  to  Elevate 
Spring  Devices — External  Apparatus  :  when  required 300-305 


10  CONTENTS 

CHAPTER    XVII 

Incisors,  to  move  Bodily 


PAGE 


Bodily  Movement  of  Incisors — Laterally — Outward — Inward — Methods  of 
Anchorage  and  Attachment  to  the  Teeth — Lateral  Expansion — 
Chin-Cap — Supplemental  Force,  with  Supralabial,  and  Infralabial 
Bar  306-323 

CHAPTER    XVIII 
Prognathism 

General — Unilateral — Age  for  Correction — Apparatus — Caps  over  the  Teeth 
— Chin-Cap  :  Its  Application — Cross-Bar — Infralabial  Bar — Casts  of 
Features  before  and  after  Correction 324-336 

CHAPTER    XIX 
Receding  Lower  Jaw 

Causes  of— Apparent  Recession — Contracting  Upper  Arch — Moving  Forward 
Lower  Incisors  and  Process — Equalizing  the  Jaws — Jumping  the 
Bite — Age  to  operate — Jumping  the  Bite  Forward — Jumping  the 
Bite  Backward — Devices 336-343 

CHAPTER    XX 

Lack  of  Occlusion 

General  Lack  of  Occlusion — Lack  of  Anterior,  Posterior,  Lateral  Occlusion 
— Grinding  Teeth— Expansion  of  the  Upper  Arch— Chin-Cap  Device 
— Depression  and  Elevation  of  the  Teeth — Artificial  Crowns — Bridge- 
Work    344-350 

CHAPTER    XXI 

Cuspids,  to  move  Outward — Forward  in  the  Line  of  the  Arch 

Apparatus  for  moving  One  or  Two  Cuspids — Compensating  Device  for 
moving  Cuspids  Outward  and  contracting  Anterior  Part  of  Arch — 
Removal  of  Alveolar  Process  to  facilitate  Regulation — Supplemental 
Force 351-361 

CHAPTER    XXII 

Cuspids,    to   move    Inward — Backward — Elevate — Depress — 

Rotate 

Applianc.'H  aruhon-d  to  the  Teeth,  including  Plates — Increasing  Space — 
Moving  Bicuspids  Backward — Ext<;rnal  Devices— Supplemental  Force 
with  Cross-Bar,  Infralabial,  or  Supralabial  Bar 362-381 


CONTENTS  11 

CHAPTER    XXIII 
Bicuspids,  to  move  Outward  or  in  a  Buccal  Direction 

PAGE 

Devices    for  moving    One  or   More  Bicuspids — Increasing  Space — Springs 

attached  for  moving  other  Teeth 382-390 

CHAPTER    XXIV 

Bicuspids,  to  move  Inward  or  in  a  Lingual  Direction 

Devices  with  a  Lingual,  and  with  a  Labial  Base-Wire — Application  of  Rubber 

Bands 391-394 

CHAPTER    XXV 

Bicuspids,  to  move  Backward  in  the  Line  of  the  Arch 

Spring-Wire  Devices — Plates — Metal  Caps  with  Eyelets — Cross-Bar  Device 

for  Uppei;  or  Lower  Arch — Infralabial  or  Supralabial  Bar  .    .    .  395-403 

CHAPTER    XXVI 

Bicuspids,  to  move  Forward — To  relieve  Impaction — Elevate 

— Depress — Rotate 

Appliances  with  Springs — Apparatus  applied  in  One  Arch  to  move  Teeth 

of  Other  Arch 404-409 

CHAPTER    XXVII 

Molars,  to  move  Outward — Inward — Forward — Backward — 
Depress — Elevate 

Movement  Outward,  Inward,  Forward  in  the  Line  of  the  Arch — Backward 

in  the  Line  of  the  Arch — Depression — Elevation 410-414 

CHAPTER    XXVIII 
Retention  of  the  Teeth 

Removable,  Fixed,  Permanent  Devices — Metal  Appliances — Collars — Spurs 
— Vulcanite  and  Metal  Plates — Object  of  Retention — Detrimental 
Effects — Length  of  Time  Teeth  should  be  retained — Hereditary  and 
Acquired  Influences — When  Retention  is  not  Necessary — Adjust- 
able Wire  and  other  Apparatus — How  constructed — Removable 
Bridge — Suspension  Plate — Lingual  Bar  Avith  Screws 415-441 


12  CONTENTS 

CHAPTER    XXIX 
General  Orthopaedia  of  the  Face 

PAGE 

Improvement  of  Contour  of  Features — Nose,  Plastic  Surgery  of — Paraffin 
Treatment  for  Deformities — Hollow  Cheeks — Eye — Ear — Cleft  Palate 
and  Harelip 442-450 

APPENDIX 

List  of  Plates — Page  Plates  of  Apparatus  used  in  Practice 451-499 


ORTHODONTIA 

CHAPTER    I 

ETIOLOGY 

The  etiological  factors  that  induce  maldevelopment  of  the  jaws 
and  irregular  positions  of  the  teeth  are  divisible  into  two  classes, 
constitutional  and  local. 

The  constitutional  causes  will  be  distinguished  as  inherited  and 
acquired. 

Some  of  the  influences  that  effect  these  maldevelopments  and 
irregularities  are  obscure.  They  are  principally  among  the  consti- 
tutional, the  local  causes  being  better  understood. 

FIeredity. — The  general  law  of  descent  from  parent  to  offspring 
is  nowhere  more  plainly  shown  than  in  the  transmission  of  char- 
acteristics of  the  jaws  and  teeth.  The  inherited  constitutional 
causes  include  the  tendency  of  healthy  persons  to  reproduce  their 
peculiarities,  whether  normal  or  abnormal.  These  peculiarities  are 
occasionally  traceable  through  three  or  more  generations,  but  they 
do  not  always  appear  continuously  ;  they  may  pass  over  two  or 
more  generations  and  then  reappear.  Again,  the  children  of  the 
same  parents  may  not  all  equally  inherit  the  same  constitutional 
tendencies.  Figs.  1,  2,  and  3  illustrate  an  interesting  case  of  heredi- 
tary transmission  of  peculiarities  of  tlie  features,  from  the  grand- 
father to  the  daughter  and  to  the  granddaughter,  the  profile  or  gen- 
eral facial  line  being  the  same,  with  upturned  pointed  nose  and 
receding  lower  jaw. 

One  of  the  most  frequent  causes  of  dental  irregularity  is  the 
intermarriage  of  individuals  of  different  race-characteristics.  A 
common  case  is  where  the  child  inherits  the  small  jaw  of  one  parent 
and  the  large  teeth  of  the  other.  There  naturally  being  insufficient 
room  in  the  arch  for  their  free  eruption,  the  teeth  become  crowded, 
spoiling  the  otherwise  even  contour  and  arrangement ;  or  the  oppo- 
site condition  may  occur,  the  large  jaw  of  one  parent  and  the  small 

13 


14  ETIOLOGY 

teeth  of  the  other  bemg  transmitted  to  the  child,  thus  causing  the 
interdental  spaces  to  be  unusually  marked. 

It  is  important  that  hereditary  malformations  of  the  child  be  cor- 
rected early,  to  prevent,  as  far  as  possible,  their  permanence,  if  not 
their  recurrence. 

Syphilis. — The  influence  of  constitutional  syphilis  on  developing 
osseous  structures  should  have  due  consideration.  The  literature 
of  the  subject  is  so  voluminous  that  the  reader  is  referred  to  recent 
text-books. 

There  is  a  morbid  constitutional  condition  affecting  the  lymphatic 
glandular  system,  generally  termed  scrofula.  During  childhood  these 
glands  undergo  their  greatest  activity  and  development.  Hence  it  is 
that  the  lymph-glands  in  the  young  are  more  prone  to  infection  and 
alterations  of  nutrition  than  in  adults.  It  is  certain  that  a  large  per- 
centage of  deformities  of  the  nose  and  jaws  result  directly  or  indi- 
rectly from  malnutrition.  At  this  time  epithelial  structures  are  also 
especially  liable  to  take  on  disease. 

Acquired  Constitutional  Causes, — Among  the  acquired  causes  of 
irregularity  of  the  teeth  and  deformity  of  the  jaws  are  those  which 
are  brought  about  by  infection  and  by  malnutrition  and  functional 
disturbances  as  exemplified  in  neuroses,  scorbutus,  and  rhachitis, 
with  nasal  obstructions,  adenoid  vegetations,  enlarged  tonsils,  hyper- 
trophy of  the  tongue,  etc. 

Neurotic  Tendencies. — As  in  all  tissues,  the  nutrition  of  the 
bones  and  teeth  is  largely  governed  by  and  dependent  upon  the  con- 
dition of  the  nervous  system. 

Kingsley  says,  in  this  connection,*  "■  Laying  aside  ail  cases  that  may 
be  due  to  an  inlierited  tendency  to  follow  or  exaggerate  some  given 
type,  together  with  those  which  are  manifestly  due  to  forces  operating 
only  after  eruption,  the  jjrimary  cause,  so  far  as  the  individual  is 
concerned,  of  any  general  disturbance  in  the  development  of  the 
permanent  teetii,  showing  itself  particularly  in  their  malposition,  is 
directly  traceable  to  a  lesion  or  innervalion  of  the  trigeminal  nerve. 

In  1809  Mummery  called  attention  to  the  overtaxing  of  the 
active  brain  of  children  as  probably  a  causal  factor.f     "According 


*  Kingsley's  Oral  Deformities,  p.  21. 

f  Miinimery,  Transactions  of  the  Odontolojjicai  Society  <jC  Great  lirilain,  1869, 
p.  73. 


Fic.  2. 


Fig.  1. 


Fi. 


^^^^m                              .^^^^^1 

KC'-^fl 

billH^^H 

ACQUIRED  CONSTITUTIONAL  CAUSES  15 

to  the  best  authorities,  the  most  rapid  increase  in  the  size  of  the 
brain  takes  place  before  seven  years  of  age  ;  and  it  must  be  remem- 
bered that  the  crowns  of  all  of  the  permanent  teeth,  with  the  ex- 
ception of  the  third  molars,  are  in  course  of  development  simulta- 
neously with  this  great  advance  in  the  size  of  the  brain.  May  we 
not  therefore  reasonably  suppose  that  through  the  diminished  vitality 
consequent  upon  this  diversion  of  the  formative  energy  from  the 
teeth,  by  premature  mental  exertion,  these  organs  necessarily  become 
degenerated ;  and  that  this  circumstance  constitutes  one  great  dif- 
ference between  the  teeth  of  the  intellectual  and  those  of  the  uncul- 
tivated families  of  mankind?" 

The  injurious  effects  of  excessive  mental  activity  on  the  develop- 
ing child  are  being  recognized  by  progressive  educators,  which  lead 
us  to  hope  that  our  school  system  and  course  of  study  may  be  so 
improved  as  to  permit  of  a  more  normal  physical  development  dur- 
ing this  important  period.* 

Infantile  Scorbutus. — Scorbutus  is  caused  by  depraved  nutrition, 
usually  resulting  from  improper  feeding.f  Symptoms  of  the  affec- 
tion are  fretfulness,  aversion  to  being  handled,  crying  out  as  if  in 
pain  when  lifted,  tenderness  of  the  lower  limbs  and  indisposition  to 
move  them,  swollen,  spongy,  bleeding  gums,  and  progressive  anaemia. 

Rhachitis. — Rickets  is  a  disease  of  childhood,  due  chiefly  to  defi- 
cient nutrition  and  bad  environment.  It  is  said  to  be  inherited  from 
the  parents  when  one  or  both  were  affected  with  a  cachexia  or  other- 
wise enfeebled  condition.  It  has  often  been  found,  however,  that  the 
child  has  suffered  from  a  lack  of  the  vital  stimuli,  light,  heat,  air, 
and  food,  from  the  use  of  food  unsuited  to  its  age,  or  from  a  lack 
of  phosphorus  combinations  in  the  blood,  with  a  deficiency  of  lime 
salts  in  the  bones.  The  lips  are  thin,  pinched,  and  drawn  ;  there  is 
retarded  and  painful  eruption  of  the  teeth,  with  unusual  constitu- 
tional disturbances  during  dentition.  Smith,  who  has  had  a  large 
experience  with  rickets,  states  that  it  most  frecjuently  occurs  at  the 
age  of  six  months  to  two  years.  Some  years  ago  Roberts  said  that 
about  thirty  per  cent,  of  children  suffer  more  or  less  from  rickets. 
Another  authority  has  written  :  "  One  child  in  five  is  aff"ected  in  good 
families."     The  early  symptoms  are  fretfulness,  tenderness  on  the 

*  Stuver,  Dietetic  and  Hygienic  Gazette,  December,  1897,  p.  784. 
f  Northrop,  Crandall,  Dental  Cosmos,  1895,  p.  503. 


16 


ETIOLOGY 


Fig.  4. 


surface  of  the  body,  perspiration,  general  arrest  of  development,  and 
bone-defomiity  later. 

It  will  be  observed,  as  we  compare  statistics,  that  there  is  but  a 
slightly  larger  per  cent,  of  cases  that  suffer  with  deformed  nasal 
septi  (which  will  be  referred  to  later  in  this  chapter)  than  are  found 
to  have  been  affected  with  some  degree  of  rhachitis,  and  that  a 
majority  of  cases  of  deflection  of  the  septum  appear  at  about  the 
same  time  as  when  the  deformity  of  ttie  upper  maxilla  is  first  seen. 
Roberts  observes  that  in  rhachitis*  the  flat  bones  are  thickened 
from  periosteal  formation,  especially  near  their  growing  edges,  as  well 

as  softened.  Green  states 
that  "  The  zone  of  the  car- 
tilaginous tissue,  which  in 
health  while  being  trans- 
formed into  bone  is  very 
thin,  in  rhachitis  is  greatly 
thickened  beneath  the  peri- 
osteum." The  alteration 
of  the  bones,  according  to 
Jenner,  consists  in  an  in- 
creased preparation  for  os- 
sification, but  an  incom- 
plete performance  of  the 
process.! 

Effects  of  Muscular  Ac- 
tion.— The  effect  of  the 
muscles  on  the  bone  and  al- 
veolar process,  when  there 
is  a  lack  of  density  of  those 
tissues,  as  in  rhachitis,  is 
often  noticeable,  causing  malformation  of  ttie  jaws  and  irregular 
positions  of  the  teeth. | 

In  Fig.  4  it  will  be  seen  that  the  distance  frum  the  junction  of  the 
maxillary  bones,  A,  to  the  centre  of  the  grinding  surface  of  the  second 
molar,  B,  is  about  the  same  as  from  the  centre  of  the  molar  B  to  the 


; 


Human  Skull,  with  Teeth  removed A,  junction 

of  the  two  maxillarj'  bones ;  B,  centre  1  inc  of  second  molar 
tooth ;  C,  line  of  outer  border  of  masseter  muscle  ;  IJ, 
outer  torder  of  zygomatic  arch ;  E,  lowest  lx)rder  of 
malar  f>rooessof  left  8iipcrior  maxillary  bone. 


*  Roberts,  Theory  and  Practice  of  Medicine,  p.  274. 

f  Jenner,  On  Rickets,  Tuberculo.sis,  Aiidominal  Tumors,  1895,  p.  13. 

X  Jackson,  Denial  Cosmos,  1890,  p.  289. 


EFFECTS   OF   MUSCULAR   ACTION  17 

line  of  the  outer  border  of  the  masseter  muscle  C.  Tlie  action  of 
this  powerful  muscle  drawiiifr  downward  on  the  zygomatic  arch  D, 
to  tlie  anterior  two-thirds  of  which  it  is  attached,  combined  with 
the  action  of  the  buccinator  and  tem])oral  nmscles,  causes  an  up- 
ward pressure  of  the  lower  jaw  against  the  superior  maxilla  at  B. 
If  tliere  is  a  lack  of  density  of  the  bones,  as  from  rhachitis  or  other 
condition,  the  downward  traction  of  the  buccinator  and  masseter 
muscles  on  the  outer  surface  of  these  bones  will  naturally  cause  a 
tipj)ing  towards  each  other  of  the  lateral  halves  of  the  upper  max- 
illa. The  bones  yield,  and  the  anterior  curve  of  the  jaw  is  nar- 
rowed laterally,  producing  the  V-  or  saddle-shaped  arch,  typical 
forms  of  which  will  be  seen  in  Figs.  16  and  18. 

This  settling  together  of  the  lateral  halves  of  the  maxilla  at  the  time 
the  jaws  should  be  developing  results  in  the  lateral  constriction  of 
the  nares  ;  and  at  the  same  time,  the  consequent  arching  upward 
of  tlie  i)alatine  portion  of  the  jaw  further  tends  to  constrict  the 
apertures.  In  these  cases  we  usually  find  the  nasal  processes  of 
the  superior  maxillary  bone  bulging  forward,  the  palatal  portion 
excessively  vaulted  and  thickened,  the  septum  of  the  nose  deflected, 
and  the  outer  border  of  the  supra-orbital  arch  sloping  downward 
more  than  usual  from  the  horizontal.  It  is  to  be  borne  in  mind  that 
the  alveolar  process  will  follow  and  support  the  teeth  in  any  position 
that  the  teeth  may  be  caused  to  assume. 

Aside  from  diseases  of  the  nasal  organs  and  from  hereditary  ten- 
dencies, it  is  thought  that  these  derangements  most  frequently  occur  as 
a  result  of  an  early  rhachitic  condition,  an  improved  nutrition  or  degree 
of  health  being  attained  afterwards,  the  malformation  persisting. 

Analogous  to  the  softened  condition  of  the  developing  bones 
during  rhachitis,  teeth  often  have  a  depressed  mark  or  sulcus 
across  their  surface,  in  wliich  mark  the  structure  is  less  dense  than 
on  either  side.  Its  width  indicates  the  checking  of  development 
during  the  course  of  some  acute  disease  that  interfered  with  nutrition. 
Third  molars  or  wisdom-teeth  at  the  time  of  eruption  are  also  de- 
ficient in  calcific  deposit,  their  development  taking  place  during  the 
time  of  the  extensive  growth  of  the  bony  frame,  and  the  teeth  there- 
fore receiving  a  lessened  nutritive  supply.  These  conditions  are 
especially  noticeable  in  the  poorly  nourislied,  but  later  in  life  wisdom- 
teeth  become  more  dense,  and  when  cared  for  often  prove  as  strong 
or  stronger  than  the  adjoining  ones.     In  the  aged  person  they  are 

2 


18 


ETI0L0C4Y 


Fi( 


generally  found  doing  service  after  the  rest  of  the  teeth  have  yielded 
to  the  ravages  of  time. 

Fig.  5  represents  a  skull  with  the  malar  bone  and  a  portion  of  the 
malar  process  removed,  exposing  the  antrum  of  Highmore.  It  has 
been  stated  that  the  frontal  sinuses,  ethmoidal  and  sphenoidal  cells, 
and  a  hollowing  out  of  the  malar  bone  for  the  antrum  are  seen 
about  the  second  year  after  birth.  Mayer*  states,  "The  order  in 
which  these  sinuses  appear  is  as  follows  :  1,  Maxillary  at  the  fourth 

fetal  month  ;  2,  ethmoidal 
at  the  seventh  fetal  month ; 
3,  sphenoidal  at  the  third 
year  of  life ;  4,  frontal  at 
the  seventh  year  of  life. 
The  maxillary  antrum  is 
well  defmed  at  birth,  but 
undergoes  little  change 
until  the  second  dentition, 
the  sixth  to  eighth  year, 
from  which  date  it  de- 
velops rapidly  in  common 
with  the  facial  bones." 

From  birth  to  full  de- 
velopment there  is  a  con- 
stant change  in  the  struc- 
ture ;  bone  is  deposited  on  the  outer  surface  with  an  absorption  of 
the  inner  surface.  The  absorption  is  slow,  and  the  walls  do  not 
reach  their  normal  thinness  until  after  the  age  of  maturity.  This  is 
important  when  we  consider  how  often  disease  attacks  the  nasal 
tissues,  and  its  effect  on  the  developing  bone  while  these  changes  are 
taking  place,  including  cases  where  there  is  an  inharmonious  develop- 
ment of  the  frontal  and  other  cranial  bones. 

In  Figs.  6  and  14  it  will  be  seen  that  the  principal  anterior  growth 
of  the  upper  maxilla  takes  place  at  the  suture  at  the  anterior  edge  of 
the  palate  bone  D.  This  bone  forms  a  portion  of  the  roof  of  the 
mouth,  floor,  outer  wall  of  the  nose,  and  floor  of  the  orbit.  It  is 
attached  by  suture  to  the  pterygoid  process  of  the  sphenoid  bone 
on  either  side  by  a  tuberosity  or  elongated  wedge,  projecting  back- 


HuiiAN  Skull,  v,-nn  Malar  Bone  removed.— a,  orbi- 
tal ridge  ;  B,  spheno-maxillary  fissure  ;  C,  antrum  of  High- 
more  ;  D,  pterygoid  proces.s  of  sphenoid  bone  ;  E,  temporal 
portion  of  zygomatic  arch;  F,  auditory  canal ;  G,  mastoid 
process. 


*  Mayer,  Medical  Record,  August  10,  1901. 


EFFECTS  OF  IMUSCULAR  ACTION 


19 


Fig.  6. 


ward  into  the  pterygoid  notch.  The  pterygoid  process  (F)  is  practi- 
cally a  fixed  point,  in  front  of  and  near  whicii  the  anterior  develop- 
ment of  the  true  maxilla  takes  place.  Tlie  sphenoid  is  termed  the 
key  of  the  cranium,  as  it  articulates  with  all  of  the  cranial  hones,  and 
also,  directly  or  indirectly,  with  the  bones  of  the  face.  As  we  ex- 
amine the  skull,  we  find  that  the  lateral  growth  of  the  sphenoid  har- 
monizes the  width  from  side  to  side  of  the  posterior  portion  of  the 
upper  and  lower  maxilla,  as  no 
doubt  it  does  other  dimensions  of 
the  skull.  The  lower  maxilla  has 
a  temporo  -  maxillary  articulation. 
Its  width  is  governed  by  the  lateral 
growth  of  the  greater  wings  of  the 
sphenoid,  which  increases  the  dis- 
tance between  the  glenoid  fossae  to 
which  the  condyles  of  the  jaw  are 
attached.  The  widtli  of  the  distal 
part  of  the  upper  maxilla  is  gov- 
erned by  the  lateral  growth  of  the 
body  and  greater  wings  of  the 
sphenoid  in  connection  witli  the 
outward  movement  of  the  ptery- 
goid processes. 

The  jaws  are  increased  by  build- 
ing additional  bone  and  process  on 
the  outer  walls.  Bones  are  the 
framework  to  which  the  muscles 
are  attached  as  stays,  and  over 
whicli  the  integument  is  drawn.  I  believe,  from  the  anatomy  of  the 
jaws,  and  from  the  large  number  of  mouths  it  has  been  my  fortune 
to  examine  and  study,  including  both  the  so-called  saddle-  and 
V-shaped  arches,  that  the  muscles  of  those  regions  play  not  a  small 
part  in  connection  with  other  influences  referred  to  in  this  chapter, 
in  causing  their  variation  from  the  normal  type  of  development. 

The  tissues  of  the  cheeks,  lips,  and  tongue  are  looked  upon  as  a 
matrix  that  influences  to  a  large  extent  the  form  of  the  dental  arch. 
This  view  has  been  advanced  by  anatomists  and  histologists  for  years, 
and  is  held  by  a  majority  of  the  profession. 

When  the  tongue  is  at  rest  in  its  natural  position  within  a  normal 


Base  of  Skull. — A,  intermaxillary  bone; 
B,  anterior  palatine  canal ;  C,  palate  process 
of  superior  maxillary  ;  D,  palate  bone ;  E, 
body  of  sphenoid  bone ;  F,  pterygoid  process 
of  spenoid  ;  G,  great  wing  of  sphenoid  ;  H, 
location  of  glenoid  fossa ;  J,  spheno-maxil- 
lary  fissure ;  K,  malar  process  of  superior 
maxillarj- ;  M,  foramen  magnum  ;  N,  nasal 
septum  (vomer).    (Gray.) 


20 


ETIOLOGY 


arch  of  teeth,  it  is  forced  forward,  icith  tJie  dorsum  in  contact  with  the 
roof  of  the  mouth  and  the  tip  curved  downward  behind  the  lower  and 
upper  incisors.  The  influence  of  the  tongue  in  shaping  the  arch  and 
equalizing  the  jaws  can  be  estimated  to  some  extent  by  the  pressure 
caused  on  the  teeth  in  the  act  of  swallowing. 

Fig.  7. 


TINDO.OCULI 


Ant.  2Tasat Spine 
Jnoieive,  fossa 


Anterior 
Hares 


Grooi/e  for  TacCal  a  V 


Anterior  region  of  skull.    (Gray.) 

It  will  be  observed  in  the  aged,  when  from  the  early  loss  of  the 
teeth  the  process  is  much  absorbed,  that  wliile  the  tongue  is  at  rest 
it  is  broadened,  so  that  the  edges  and  the  tip  are  in  contact  with  the 
cheeks  and  lips.  In  mouth-broathing,  the  jaws  being  separated,  these 
tissues  not  only  press  unequally  on  the  developing  osseous  structures, 


EFFECTS   OF  MUSCULAR  ACTION  21 

but  the  tongue  is  taken  away  from  its  normal  position,  being  drawn 
downward,  removing  the  inner  part  of  the  matrix  or  support  from 
the  upper  arch.  The  outer  matrix  consists  of  the  muscles  and  other 
tissues  of  the  lips  and  cheeks.  All  muscles  have  a  natural  tonicity. 
The  orbicularis  oris  is  a  sphincter  muscle.  When  the  lips  are  closed 
it  is  at  rest ;  when  the  mouth  is  open,  as  in  mouth-breathing,  the 
orbicularis  oris,  the  buccinator,  and  other  muscles  are  put  on  the 
stretch.     Many  of  the  fibres  of  these  muscles  blend. 

The  origin  and  insertion  of  the  buccinator  muscle  are  from  the 
outer  surface  of  the  alveolar  process  of  the  upper  and  lower  jaws 
(Fig.  7).  In  mouth-breathing,  the  jaws  are  separated,  and  the  con- 
sequent unnatural  continuous  tension  of  this  muscle  on  the  outer 
walls  of  the  alveolar  process  of  the  jaws  changes  their  form,  ele- 
vating the  teeth  of  this  region  and  tipping  them  inward.  This  is 
sometimes  more  apparent  with  the  teeth  of  the  lower  arch. 

The  changing  of  the  process  in  this  manner,  causing  elevation  of 
the  teeth,  may  be  confined  to  the  distal  part  of  the  arch,  the  extru- 
sion of  the  teeth  causing  lack  of  anterior  occlusion.  In  other  cases 
of  mouth-breathing  there  is  also  a  drawing  downw-ard  of  the  muscles 
on  the  process  in  the  anterior  part  of  the  arch,  causing  a  general  ele- 
vation of  the  teeth. 

The  orbicularis  oris  is  composed  of  concentric  fibres  which  sur- 
round the  orifice  of  the  mouth  (Fig.  8).  It  consists  of  two  thick 
semicircular  planes  of  muscular  fibre,  which  interlace  on  either  side 
with  those  of  the  buccinator  and  other  muscles  inserted  into  the 
lips.  To  both  the  upper  and  the  lower  segments  some  special  fibres 
are  added,  by  which  the  lips  are  connected  directly  with  the  upper 
and  lower  maxillary  bones  and  to  the  septum  of  the  nose.  The 
additional  fibres  for  the  lower  segment  arise  from  the  inferior  maxilla, 
externally  to  the  levator  labii  inferioris.  Those  of  the  upper  seg- 
ment are  of  four  bands,  two  arising  from  the  alveolar  border  of  the 
upper  maxilla  opposite  the  incisor  teeth,  and  two  connecting  the 
upper  lip  to  the  septum  of  the  nose,  one  on  either  side.  When  the 
mouth  is  held  open  continuously,  as  in  mouth-breathing,  the  dragging 
of  the  muscles  on  the  process  gradually  elevates  it  with  the  teeth, 
sometimes  lengthening  the  features  and  making  it  difficult  to  close 
the  lips,  or  causing  an  excessive  lap  of  the  teeth  in  occlusion,  at  the 
same  time  pulling  downward  on  the  nose.  In  Fig.  3  is  illustrated  a 
case  of   contraction  of  the  muscles  in  the  effort  to  close  the  lips, 


22 


ETIOLOGY 


causing  extreme  downward  traction  on  the  soft  tissues,  elevating  the 
teeth,  and  also  drawing  down  on  and  distorting  the  nose.     This  is 


Fig.  8. 


CORRUCATQR 


CIATMKAHIS 
mttet  mm 

UfUttU  UK  HASI 


Muscles  of  the  head,  fane,  and  neck.     (Gray.) 


relieved  by  depressing  the  teeth  hi  their  sockets,  thus  permitting  the 
lips  to  close  more  freely.  On  the  other  hand,  the  set  expression  of 
the  lips,  from  their  resting  too  firmly  together,  usually  results  from 


EFFECTS  OF  MUSCULAR  ACTION      '  23 

excessive  loss  of  the  occlusal  surfaces  of  the  teeth  from  abrasion,  or 
from  the  depression  of  the  occluding  teeth  with  the  process. 

That  the  orbicularis  oris  and  buccinator  muscles  act  in  harmony  is 
shown  by  the  action  of  the  buccinator  in  chewing  hard  substances  on 
one  side  of  the  mouth,  when  at  each  contraction  the  lips  are  drawn 
towards  that  side.  It  is  the  contraction  of  these  muscles  that  causes 
the  dimple  in  the  cheek. 

As  the  healthy  tonicity  of  the  muscles  produces  a  natural  tension 
in  them  even  when  at  rest,  we  should  not  underestimate  their  power 
to  influence  developing  bone.  This  natural  tonicity  of  the  muscles 
is  more  noticeable  in  some  individuals  than  in  others.  That  these 
tissues  tend  to  influence  the  curve  of  the  arch  and  position  of  the 
teeth  is  further  illustrated  in  cases  where  one  or  more  teeth  have 
been  removed  on  one  side  to  relieve  an  overcrowded  arch,  and  the 
central  incisor  of  the  opposite  side  has  been  forced  far  over  the 
median  line  towards  the  space  caused  by  extraction,  with  the  circle 
of  the  arch  still  preserved.  Another  example  is  where  the  wisdom- 
tooth  has  erupted  towards  the  cheek,  in  which  case  it  is  gradually 
directed  by  the  pressure  of  the  muscle  to  its  normal  position.  Also 
when  the  muscles  are  paralyzed  on  one  side  of  the  face  by  an 
arrest  of  the  nerve-stimulus,  the  soft  tissues  are  drawn  towards 
the  other  side  of  the  face  by  the  natural  pull  of  the  muscles  not 
affected. 

The  influence  of  the  lips,  cheeks,  and  tongue  on  the  developing 
arch  can  be  understood  by  noticing  their  position  in  the  edentulous, 
the  lips  being  always  turned  inward  ;  and  the  natural  contraction  of 
the  lips  often  presses  backward  full  plates  of  artificial  teeth  that  have 
been  adjusted,  where  there  is  much  absorption  in  either  the  upper  or 
lower  jaw,  so  that  the  plates  have  to  be  readjusted  with  a  view  to 
this  pressure.  The  contraction  of  scar-tissue  draws  on,  and  in  some 
cases  changes  materially,  the  form  of  the  process  and  position  of  the 
natural  teeth.  The  continued  traction  of  the  congenital ly  shortened 
frenum  often  alters  the  process,  and  there  may  be  a  lack  of  symme- 
try of  the  skull  of  the  babe  which  has  become  flattened  from  being 
allowed  to  lie  more  on  one  side  than  on  the  other. 

Virchow,  in  speaking  on  the  influence  of  the  muscles  on  the  pelvis 
when  the  bones  are  softened  from  rhachitis,  says,  "All  these  changes 
are  to  be  attributed  to  the  traction  of  the  muscles  and  ligaments,  as 
well  as  to  the  partial  stoppage  in  the  development  of  bone." 


24  ETIOLOGY 

Fleischmann  accounts  for  the  changes  in  the  shape  of  the  lower 
and  the  upper  jaw  by  the  contraction  of  the  muscles.* 

Mouth-Breathing-. — The  general  causes  of  mouth-breathing  and 
its  detrimental  effect  on  the  development  of  the  nose  and  maxilla  will 
now  be  considered.  Mouth-breathing  becomes  a  habit  from  neces- 
sity. The  partial  occlusion  of  one  or  both  nasal  fossae  from  any 
cause  is  likely  to  make  the  patient  a  mouth-breather.  It  is  the  duty 
of  the  practitioner  to  direct  the  attention  of  parents  to  the  inevi- 
table troubles  that  will  arise  if  the  impediment  to  free  nasal  respira- 
tion is  not  removed  so  that  the  child  may  breathe  freely  through  the 
nose.t 

Mouth-breathing  is  usually  accompanied  with  a  disease  of  the 
glandular  structures  in  the  naso-  or  oro-pharynx.  The  posterior 
portion  of  the  mouth  has  a  chain  of  glands  known  as  Waldeyer's 
ring.  These  consist  of  the  faucial  tonsils,  the  lingual  tonsils,  and 
the  third  or  Luschka's  tonsil,  familiarly  known  as  adenoids. 

Enlarged  Tonsils. — Chronic  enlargement  of  tonsillar  tissues  is  one 
of  the  causes  of  mouth-breathing.  It  is  a  disease  of  child-life. 
Some  authors  claim  that  enlargement  of  these  glands  has  been 
observed  in  children  born  even  before  term,  indicating  direct  he- 
redity ;  others  think  that  it  is  not  congenital.  Enlargement  of  the 
faucial  tonsils  is  said  to  occur  more  frequently  in  the  male.  Rice 
says,  "  Ninety  per  cent,  of  the  class  of  cases  termed  mouth-breathers 
in  children  are  not  simple  ailments  of  catarrhal  disease  of  the  nose, 
but  are  evidences  of  obstruction  which  prevents  nasal  respiration. 
This  obstruction  is  largely  due  to  the  presence  of  enlarged  tonsils. "J 
Hypertrophy  of  the  lingual  tonsil  does  not  generally  become  evident 
before  the  age  of  sixteen.  It  occurs  more  commonly  in  the  female. 
Hypertrophy  of  the  pharyngeal  or  Luschka's  tonsil  will  be  considered 
under  adenoid  growths. 

It  is  my  opinion  that  the  same  systemic  conditions  that  bring 
about  an  enlargement  of  these  glands  are  operative  in  inducing  some 
of  the  other  conditions  found  in  nasal  stenosis  that  often  accompa- 
nies them.  Such  are  rhinitis,  deflection  of  the  septum,  and  malde- 
velopment  of  bones,  each  of  which  will  be  considered  in  its  place. 

*  Ziemssen,  Cyclopaedia  of  tin;  I'raclice  of  MetJicirif;,  Supplement,  p.  109. 

f  Jackson,  Dental  Cosmos,  1890,  p.  289. 

j  Rice,  Medical  News,  February  4,  1899,  p.  IT)!. 


MOUTH-BREATHING,  RHINITIS,  ADENOID  GROWTHS  25 

Rhinitis. — Chronic  rhinitis,  or  inflammation  of  the  membranes  of 
the  nose,  due  orig-inally  to  some  form  of  infection,  influences  the 
adjacent  developing  bony  structures,  either  stimulating  or  arresting 
their  growth  according  to  the  activity  of  the  afl'ection. 

In  the  lighter  forms  of  rhinitis  the  natural  blood  supply  is  stimu- 
lated, adding  to  the  nutrition,  j)articularly  at  the  sutures.  This  may 
result  in  an  increased  growth  which  may  be  shown  in  the  prominent 
maxilla. 

In  the  pronounced  forms  of  rhinitis  the  membranes  are  thickened, 
interfering  with  nasal  respiration.  There  is  more  congestion  and 
stagnation  of  the  circulation.  The  nutrition  is  interfered  with 
and  the  vessels  become  much  enlarged,  resulting  in  partial  or 
general  arrest  of  development  of  the  bone  and  alveolar  process. 
This  is  not  uncommon.  It  may  be  apparent  in  the  flattened  and 
sunken  appearance  of  the  middle  third  of  the  face  in  the  region  of 
the  nose. 

True  inflammation   of  the  mucous  membrane  results  in  hyper- 
trophy of  the  connective  tissue.     Of  one  thousand  cases  that  pre- 
sented  themselves    for   treatment   at   a    New  York   Eye    and   Ear 
Infirmary,    seven    hundred     and 
seventy-one  were  found  to  be  suf- 
fering with  some  form  of  rhinitis. 

Adenoid  Gro-wi^hs,  or  Hyper- 
trophy of  the  Ling-ual  or  Lusch- 
ka's  Tonsil,  as  a  Cause  of  Nasal 
Obstruction.  — Adenoid  growths 
are  rounded  elevations  of  hyper- 
trophied  tissue  found  in  the  vault 
of  the  oro-  or  naso-pharynx  (Fig. 
q^       Thev  are    the    result   of   in-       ^'^^'^o^'^  ^'■o^^t^s  *"  t^^  "pp'^''  p^^*  «f  ^^^ 

V).        i-imy    die     UlU     lessUlL    Ul     lll        pharynx  (.l),  obstructing  the  nasal  passage  (2J), 
flammation  of  the  lymphoid  tissue.      ^"<^  encroaching  upon  the  Eustachian  tube  (C). 
/       ^  (Lefferts.) 

Gleitsman*    describes    the    chain 

of  lymphatic  glands  as  appearing  in  an  aggregated  as  well  as  a 
disseminated  form,  and  distributed  uninterruptedly  throughout  the 
pharynx  and  nasopharynx. 

Especial  attention  was  first  called  to  these  abnormal  growths  by 

*  Gleitsman,  Hyperplasia  of  the  Lymphatic  Tissue  of  the  Pharynx  and  Naso- 
pharynx, Medical  News,  January  19,  1889,  p.  62. 


26 


ETIOLOGY 


Wilhelm  Meyer,  of  Copenhagen,  in  1870.*     He  gave  to  them  the 
name  Adenoid  Vegetations  in  1868. 

He  described  two  forms,  the  cristate,  covering  the  posterior  walls 
of  tiie  pharynx,  especially  the  upper  curved  part  back  of  the  soft 
palate,  and  the  cylindrical,  occupying  the  lateral  walls.  The  growths 
may  be  brittle,  hard  or  tough,  and  at  times  soft  and  friable,  but  are 
all  composed  of  the  same  adenoid  tissue. 

Meyer  states  that  the  mucous  secretion  from  the  adenoid  vegeta- 
tions is  commonly  abundant, 
and  the  tissue  around  them  is 
always  in  a  state  of  chronic  ca- 
tarrh. The  neighboring  parts 
covered  with  mucous  mem- 
brane are  usually  found  in  an 
abnormal  slate,  as  the  Eusta- 
chian tube  and  the  middle 
ear,  the  turbinated  bones,  the 
soft  palate,  and  the  tonsils. 
The  growths  obstruct  the  pos- 
terior nasal  orifices,  as  seen  in 
Fig.  10,  A.  The  obstructions 
may  give  rise  to  any  of  the 
following  characteristic  com- 
plications :  in  infancy,  inter- 
ference with  nursing;  later, 
narrow  nasal  orifices,  dull 
and  stupid  facial  expression 
(Figs.  11  and  12),  breathing 
through  the  mouth,  especially 
at  night,  snoring,  sucking  the  air,  "dead"  pronunciation,  languor, 
and  irritability.  The  "  dead"  speech  is  composed  of  two  constitu- 
ents,— first,  the  impossibility  of  pronouncing  llie  nasal  sounds,  m,  n, 
ng;  secondly,  the  loss  of  resonance  in  the  anterior  and  posterior 
nares. 

The  predisposing  causes  are  youth,  heredity,  malnutrition,  and 
frequently  coryza,  measles,  and  local  irritations. 

It  will  be  remembered  liiat  the  chronic  congestion  accompanying 


Adenoid  development  {A),  interfering  with  nasal 
breathing  by  closing  the  >ir>r'er  jmrt  of  ihe  pharynx. 
(Delavan.) 


*  Meyer,  Transactions  Medico-Chirur^jical  Society,  London,  1870,  vol.  liii. 


FiG.    11. 


Uoy.      Characteristic  facial  expression  caused  by  adenoid 
vegetation.     (Hooper.) 


Girl,  aged  twelve  years.      Characteristic  facial  exfiression 
caused  by  adenoid  vegetation.     (FTooper.) 


ADENOID   GROWTHS  27 

these  growths  is  sufficient  to  affect  the  nutrient  supply  of  the  sutures 
or  edges  of  the  bones  Avhere  the  expansive  growth  takes  place 
(Fig.  6).  If  these  conditions  are  not  corrected,  it  may  result  in  ill- 
developed  bones  of  the  face,  narrow  nasal  chambers,  deformed 
upper  jaw,  high  palatine  narrow  dental  arch,  irregular  positions 
of  the  teeth,  misshaped  chest  walls,  middle  ear  disease  with  deafness. 

Usually  the  symptoms  are  sufficient  for  the  diagnosis,  but  fre- 
quently there  are  complications  which  require  a  physical  examina- 
tion to  be  made,  with  a  suitable  mirror,  or  with  the  index-finger. 
Mayer*  has  called  attention  to  the  ready  diagnosis  of  this  affection 
by  inspection  of  the  pharynx.  He  finds,  in  all  unoperated  cases,  the 
pharyngeal  wall  to  be  the  seat  of  small  follicles,  identical  with  the 
follicular  pharyngitis  of  adults,  and  their  presence  leads  him  invaria- 
bly to  a  diagnosis,  without  the  introduction  of  the  finger,  which  is 
exceedingly  annoying  to  a  child. 

It  is  noteworthy  that  the  removal  of  the  nasal  obstruction  improves 
the  general  health  and  bodily  weight  to  a  remarkable  degree. 

It  is  claimed  by  Frankenbergerf  that  in  deaf  mutes  there  is  a 
much  larger  percentage  of  adenoids  than  in  the  general  run  of 
children. 

Frankel  denies  that  the  lymphoid  tissue  is  more  common  with  the 
high  arch  palate  than  with  the  normal. 

The  late  Dr.  F.  H.  Hooper,  in  1888-89|,  called  attention  to  the 
defective  development  of  the  upper  maxilla  associated  with  adenoid 
vegetations,  especially  to  the  high  palatine  arch,  and  stated  that  imper- 
fect nasal  respiration  in  the  child  means  imperfect  health  and  imper- 
fect development,  and  that  "the  immediate  and  remote  effects  of 
adenoid  vegetation  depend  chiefly  upon  the  mechanical  obstacle 
which  they  offer  to  the  passage  of  air  through  the  natural  respiratory 
channels."  He  also  referred  to  the  necessity  of  their  early  removal 
on  account  of  the  injurious  effects  on  the  development  of  the  bone 
and  the  general  health  of  the  child,  and  quoted  as  follows  : 

"  Dr.  Chatellier,  of  Paris,  in  1886,§  called  attention  to  the  deformi- 


*  Mayer,  Transactions  American  Laryngological  Association,  1903. 
f  Frankenberger,   Annals  of  Otology,  Rhinology,  and  Laryngology,   1897,  p. 
395. 

J  Hooper,  Boston  Medical  and  Surgical  Journal,  March,  1888. 
§  Chatellier,  Des  Tumeurs  Adenoides  du  Pharynx,  Paris,  1886. 


28 


ETIOLOGY 


Fig.  13. 


ties  of  the  head  and  face  resultmg-  from  neglected  adenoid  growths. 
He  pointed  out  that  the  air  cavities,  as  the  frontal,  sphenoidal,  and 
ethmoidal  sinuses,  and  the  antrum  of  Highmore,  being  normally  in 
communication  Avith  the  air,  cease  to  develop  when  the  circulation 
of  air  through  the  nose  is  interfered  with,  and  alters  the  propor- 
tions of  the  face.  The  lower  jaw,  which  follows  its  normal  develop- 
ment, often  protrudes  over  the  upper  jaw,  which  is  contracted  in 
front,  the  upper  lip  is  drawn  up,  while  the  hard  palate,  from  the 
constant  atmospheric  pressure  w'ithin  the  mouth,  is  pushed  upward, 
terminating  in   a   sharp   angle  like   the  gothic  arch.      It  does  not 

seem  at  all  unlikely  that 
the  many  cases  of  deafness 
due  to  ankylosis  of  the 
ossicles,  or  other  structural 
changes  in  the  middle  ear, 
and  which  are  associated 
with  the  V-shaped  palatine 
arch  and  contracted  upper 
jaw,  are  the  remains  of 
these  adenoid  growths, 
which  accomplished  their 
destructive  work  early  in 
life  undiscovered  and  un- 
suspected," 

Figs.  11,  12  and  13,  with 
others,  were  used  by  Dr. 
Hooper  to  illustrate  the 
facial  characteristics,  the 
position  of  the  teeth,  and 
the  shape  of  the  jaws  of  si)ecial  cases  that  were  presented  at  the 
Throat  Department  of  the  Boston  City  Hospital. 

Deflection  of  the  Septum  as  a  Cause  of  Nasal  Obstruction. — 
The  nasal  septum  is  a  thin  vertical  partition  formed  principally  with 
the  vomer,  the  perpendicular  lamella  of  the  ethmoid  bone,  and  a 
cartilage  of  triangular  shape,  which  separates  the  nasal  fossae  from 
each  other,  and  hence  is  sijoken  of  as  the  carlilagitious  and  bony 
septum. 

Delavan  remarks,  "The  .septum  is  destined  lo  serve  as  a  prop, 
pushing  apart  the  upper  maxilla  from    tiui  base  of  the   skull,  and 


Contracted  arch  caused  by  adenoid  vegetation. 
(Hoo7)er. ) 


DEFLECTION  OF  THE  NASAL  SEPTUM  29 

when  it  is  crowded  upward  by  the  hard  palate  until  it  can  no  longer 
resist  the  pressure  brought  to  bear  upon  it,  deflection  results.  ...  A 
diagnostic  sign  of  an  habitual  mouth-breather  is  a  high  arch  and  a 
narrow,  hard  palate,  associated  with  deflection  of  the  nasal  septum."* 
We  also  usually  find  in  these  cases  a  projecting  forward  of  the  nasal 
prominences  of  the  ujjper  maxillary  bone. 

Deflection  of  the  nasal  septum  is  important  to  us,  because,  first,  it 
is  considered  a  cause  of  mouth-breathing ;  secondly,  it  is  generally 
associated  with  the  saddle-  and  V-shaped  arch.  It  is  estimated  that 
from  thirty  to  fifty  per  cent,  of  the  European  races  have  more  or 
loss  deviation  of  the  septum.  "  In  the  examination  of  hundreds  of 
specimens  of  the  American  Indian,  it  is  difficult  to  find  a  case  of 
marked  deflection."  However,  in  my  examinations  of  a  considerable 
number  of  skulls  in  museums,  in  those  from  the  tribe  known  as  the 
Flatheads  a  marked  deflection  was  found  ;  caused,  probably,  by 
the  external  mechanical  downward  pressure  on  the  frontal  and 
ethmoidal  bones. 

The  septum  is  first  seen  deflected  in  about  the  seventh  year,  but  the 
two  lamellae  do  not  unite  until  about  the  age  of  puberty.  Robertson 
examined  one  hundred  and  sixty  children,  from  two  to  ten  years  of 
age,  and  found  only  seven  deformities  of  the  septum,  four  of  these 
with  a  history  of  injury ;  but  in  a  total  of  seventy-two  children,  be- 
tween ten  and  twenty  years  of  age,  were  found  twenty-two  deformi- 
ties. In  some  districts  a  much  larger  percentage  of  children  than 
this  suffer  with  deformed  nasal  septi.  There  is  no  record  in  this 
report  of  the  condition  of  the  teeth  and  jaws,  but  it  will  be  seen  that 
the  early  deformity  of  the  septum  appears  at  about  the  time  of  the 
eruption  of  the  permanent  teeth.  Delavan  states,  "  Deflection  of  the 
nasal  septum  proper  may  be  due  either  to  trauma  or  improper  nu- 
trition, usually  the  latter,"  and  "  Palate  deformities  come  from  atmos- 
pheric pressure,  from  the  occlusion  of  the  nasal  passages,  creating  in 
them,  through  the  act  of  inspiration,  a  partial  vacuum,  and  thus 
changing  the  equilibrium  of  the  pressure  upon  the  upper  and  lower 
aspects  of  the  roof  of  the  mouth."  To  this  atmospheric  pressure 
are  also  attributed  many  of  the  serious  inflammations  of  the  mem- 
branes of  the  nose.  Eustachian  tube,  and  inner  ear. 

Deflection  of  the  septum,  like  the  high  vault  of  the  superior  max- 

*  Delavan,  Transactions  American  Laryngological  Association,  1887,  p.  202. 


30 


ETIOLOGY 


ilia,  is  more  common  in  the  highly  civilized.  It  is  readily  diagnosed ; 
there  is  usually  much  external  deformity,  the  nostril  on  the  affected 
side  is  occluded  (for  it  is  usually  one-sided,  though  it  may  be  double), 
and  there  is  a  corresponding  concavity  on  the  unaffected  side.  If  the 
subject  is  directed  to  obstruct  each  of  the  nasal  openings  separately, 
and  to  blow,  a  free  current  of  air  will  pour  out  of  the  cavity  on  the 
unaffected  side,  while  a  very  thin  current  of  air  or  none  at  all  ap- 
pears at  the  occluded  side. 

Ziem,  of  Germany,  in  his  experiments  on  growing  animals  to  de- 
termine the  cause  of  nasal  stenosis,   obstructed   one   nasal  orifice, 


Fig.  14. 


Permanent  teeth. 

6th-Yr.  Molar 

7th-Yr.,  Cent.  Inc. .  V- 

8th- Yr.,  Lat.  Inc.. 

9th- Yr.,  IstBic 

lOth-Yr.,  2d  Bic 

llth-Yr.,  Cuspid.... 
12th-Yr.,  2d  Molar. . 

18th- Yr.,  3d  Molar. . 


Deciduous  teeth 


—Cent.  Inc.,  5  to   8  m. 

Lat.  Inc.,    7  to  10  m. 

Cuspid,      12  to  18  m. 

1st  Molar,  14  to  16  m. 

2d  Molar,  16  to  36  m. 


A  drawing  to  illustrate  the  progressive  normal  development  of  the  upper  maxilla  and  that  of 
the  saddle-  and  V-shaped  arch,  the  time  and  order  of  the  eruption  of  the  deciduous  and  perma- 
nent teeth,  etc. 

thus  withdrawing  the  normal  nutrition  from  that  one,  contrasting  it 
willi  its  follow.  As  a  result,  which  illustrates  the  effect  of  stenosis  on 
the  development  of  the  bones,  there  was  observed  a  deviation  of  the 
intermaxillary  bone  and  the  sagittal  suture  towards  the  occluded  side, 
a  shortening  of  the  nasal  bone,  frontal  bone,  horizontal  plate  of  the 
palate  bone,  flattening  of  the  alveolar  process,  and  a  reduction  of  the 
distance  between  the  auditory  canal  and  the  alveolar  process,  as  well 
as  between  the  zygomatic  arch  and  the  supra-orbital  border. 


THE   DENTAL  ARCH      '  31 

Normal  and  Abnormal  Dental  Arch.* — The  accompanying  draw- 
ing, Fig.  14,  is  intended  to  guide  the  student  to  a  clearer  compre- 
hension of  the  progressive  stages  of  development  of  the  maxillary 
bones,  the  time  and  order  of  the  eruption  of  the  teeth,  and  to  a 
more  definite  understanding  of  the  causes  of  the  changes  from  the 
normal  to  the  abnormal  arch.  To  fully  comprehend  and  fix  the 
variations  in  mind,  one  should  make  a  similar  drawing,  first  outlining 
the  normal  shape  of  the  arch  of  a  child,  and  pencil  successively  the 
deciduous  teeth  in  place  in  the  order  of  their  development,  noting 
tlie  average  age  at  the  time  of  the  eruption  of  each  as  seen  at  the 
right  of  the  drawing.  On  the  left  side,  note  the  usual  order  and  the 
approximate  time  of  the  eruption  of  the  permanent  teeth.  The  first 
permanent,  or  sixth-year  molars  are  added  to  the  drawing  in  their 
respective  positions,  and  the  lines  representing  the  additional  develop- 
ment of  the  anterior  border  of  the  malar  processes  of  the  superior 
maxilla  are  continued  outward  at  the  same  angle.  The  lines  to 
represent  the  posterior  border  of  the  palatal  bones,  malar  processes, 
and  sutures  connecting  the  malar  bones  are  then  made.  These  lines 
represent  the  extent  of  the  growth  of  the  bones  from  the  time  of  the 
eruption  of  the  second  deciduous  molars,  at  about  two  and  one-half 
years,  to  that  of  the  first  permanent  molars,  at  about  the  sixth  year. 

The  permanent  central  and  lateral  incisors  are  then  sketched  in 
position  in  advance  of  the  deciduous  ones,  according  to  the  lines  of 
the  arch  which  it  is  intended  to  represent, — either  the  normal,  the 
the  saddle-,  or  the  V-shaped  arch,  or  their  variation.  After  this,  the 
outlines  of  the  first  and  second  bicuspids  are  marked  in  place  of  the 
deciduous  molars.  These  are  followed  by  the  insertion  successively 
of  the  permanent  cuspids,  second  and  third  molars,  Avith  the  proper 
enlargement  of  the  other  portions  of  the  drawing. 

V-Shaped  Arch ;  Anterior  Protrusion  of  the  Teeth. — The 
marked  influence  on  the  shape  of  the  upper  arch  by  the  hiter- 
maxillary  bone  which  supports  the  incisors,  and  the  growth  of 
which  is  normally  active  at  the  time  of  their  eruption,  should  re- 
ceive careful  consideration.  The  development  may  be  stimulated, 
or  arrested  by  interference  with  its  nutrition,  which  is  common  with 
nasal  affections. 

It  will  be  observed  that  the  anterior  palatine  fossa  or  canal  at 

*  Jackson,  Dental  Cosmos,  1890,  p.  292. 


32 


ETIOLOGY 


birth  is  just  posterior  to  the  central  incisors,  and,  after  all  of  the  per- 
manent teeth  are  erupted,  it  is  found  some  distance  from  them.  This 
change  is  accounted  for  by  the  anterior  growth  of  the  intermaxillary 
bone  and  the  process.     In  specimens  of  the  V-shaped  arch,  where 


Fig.  15. 


>^- 


FiG.  16. 


the  upper  incisors  were  much  too  prominent,  the  fossae  were  found 
at  a  greater  distance  back  of  the  teeth  than  in  either  the  saddle-  or 
normally  shaped  arch. 

The  lateral  incisors  in  their  alveoli  occupy  a  position  slightly  pos- 
terior to  the  line  of  the 
central  teeth,  and  erupt 
several  months  later.  It 
often  occurs  that  the  time 
of  the  eruption  of  the 
laterals  is  delayed  and  they 
assume  a  position  some- 
what posterior  to  the  cen- 
trals, which  they  force  for- 
ward with  the  process  (Fig. 
15). 

The  incisors  may  take 
all  imbricated  position,  one 
overlapping  the  other,  or 
both  of  the  centrals  may 
be  forced  forward  together, 
their  mesial  surfaces  resting 
in  contact  near  their  incisive  edge.  This  tends  to  rotate  them  out- 
ward, and  when  the  permanent  cuspids  are  erupted,  they  wedge  their 


V-SHAPED  ARCH 


33 


way  into  place,  causing  the  incisors  and  process  to  become  still  more 
prominent  without  a  corresponding-  lateral  development  of  the  pre- 
maxillary.  This  usually  results  in  a  partial  or  complete  V-shaped 
arch  with  high  vault  (Fig.  16). 

The  lower  arch  seldom  assumes  a  V-shape.  Fig.  17  illustrates  a 
case  with  this  condition,  which  was  accompanied  with  a  V-shaped 
upper  arch. 

Dr.  J.  Solis-Cohen  has  called  attention  to  exostosis  of  the  hard 
palate  in  connection  with  the  arching  of  the  roof  of  the  mouth. 
This    is     often     found 

more   or  less  marked,  ^^' 

and  in  some  cases  witli 
a  bony  ridge  on  either 
side  of  the  septum  along 
the  line  of  the  suture. 
Generally  these  condi- 
tions are  accompanied 
with  stenosis. 

Anterior  pro^rttston. 
of  the  teeth  may  result 
from  various  influences. 

The  excessive  de- 
velopment  of  the  bone 

and  process  that  support  these  teeth,  as  has  been  shown,  may  be 
the  result  of  heredity,  or  of  an  acquired  constitutional  condition. 
Many  references  and  suggestions  regarding  these  conditions  are  found 
in  other  parts  of  this  chapter. 

Local  Causes  of  Pi'otrusion. — Under  local  causes  of  protrusion 
may  be  mentioned  the  too  long  retention  of  the  deciduous  superior 
incisors,  causing  the  permanent  incisors  to  erupt  in  front  of  them ; 
and  the  injudicious  extraction  of  the  inferior  deciduous  or  permanent 
molars,  which  interferes  with  the  anterior  development  of  the  lower 
jaw,  while  the  upper  arch  is  allowed  to  attain  its  normal  develop- 
ment, giving  the  effect  of  abnormal  protrusion.  Sucking  or  biting 
the  lower  lip,  or  the  continued  resting  of  the  upper  incisors  on  the 
lip,  all  have  their  influence  in  moving  the  upper  incisors  outward. 
The  last  is  especially  important,  as  the  upper  incisors  are  always 
gradually  forced  farther  forward  when  the  lower  lip  rests  underneath 
them. 


34 


ETIOLOGY 


Saddle-Shaped  Arch. — In  tlie  saddle-shaped  arch,  both  the  alve- 
olar process  and  the  teeth  in  the  region  of  the  bicuspids  and  first  molars 
are  pressed  towards  the  median  line,  and  in  some  instances  one  or 
more  of  the  teeth  are  forced  to  erupt  entirely  inside  of  the  circle,  with 
tlie  space  closed  as  seen  in  Fig.  18.  Generally  the  saddle-shaped  arch 
is  not  apparent  before  tiie  time  of  the  eruption  of  the  bicuspids.  It 
may  be  the  result  of  heredity,  an  acquired  or  a  local  influence. 

I  had  recently  under  treatment  a  marked  case  of  saddle-shaped 

lower  arch  with  deciduous  teeth,  in  a  child  aged  seven  years.    He  was 

a  mouth-breather,  due  to  enlarged  tonsils  and  lymphoid  vegetations. 

The  prominence  of  the  malar  process  of  the  superior  maxillary 

bone  extends  as  far  forward  as  the  first  deciduous  molar,  and  in  the 

adult  it  usually  shades 
out  opposite  the  second 
bicuspid.  The  down- 
ward traction  of  the 
masseter  muscle  on  the 
zygomatic  arch  (Fig.  4, 
D),  in  connection  with 
the  action  of  the  bucci- 
nator muscle,  causes  at 
the  same  time  a  lateral 
pressure  towards  the  me- 
dian line,  and,  especially 
when  there  is  a  lack  of 
density  of  tlie  bones  from 
malnutrition,  the  malar 
process,  whicli  is  of  true  bone,  and  therefore  naturally  harder  than 
the  alveolar  structure,  tends  to  press  the  teeth  of  this  region  with 
the  alveolar  process  towards  the  median  line  of  the  arch.  It  is  this 
prominence  of  true  bone  which  remains  in  the  edentulous  after 
partial  absorption  of  the  alveolar  i)rocess,  and  not  uncommonly 
interferes  with  the  wearing  of  artificial  dmlures.  It  s(jiiielinu'S  com- 
plicates the  oijeralioii  of  expanding  the  arch,  as  true  bone  is  not 
absorbed  so  readily  as  the  alveolar  process,  and  the  roots  of  the 
teeth  are  forced  over  it,  which  elongates  them.  The  traction  of  the 
buccinator  in  conncrljon  with  (tthcr  nnisclcs  in  iiionlh-breathing  has 
an  influence  on  th(;  form  of  l)otli  the  up{)er  and  lower  arches.  The 
origin  and  insertion  of  the  buccinator  muscle  is,  as  we  have  seen,  to 


SADDLE-SHAPED  ARCH— PROGNATHISM  35 

the  outer  border  of  the  alveolar  process  opposite  tlie  bicuspid  and 
molar  teetli  (Fig.  7).  Its  action  when  tlie  jaws  are  separated  in 
mouth-breathing  sometimes  [[\)S  these  teeth  inward  and  elevates 
them  with  the  process.  This  is  often  especially  noticeable  at  about 
the  time  of  their  eruption. 

The  saddle-shaped  arch  is  more  commonly  seen  in  the  upper  than 
in  the  lower  arch.  It  is  usually  accompanied  with  nasal  obstruction 
and  enlarged  tonsils.  When  it  is  the  result  of  a  locdl  cause,  it  is 
generally  from  the  deciduous  cuspids  or  molars  having  been  lost 
prematurely,  and  the  permanent  cuspids  taking  their  position  before 
the  eruption  of  the  bicuspids.  When  it  is  time  for  the  bicuspids  to 
erupt,  there  is  insufficient  space,  and  they  are  crowded  towards  the 
median  line  or  towards  the  cheek. 

Sometimes  the  bicuspids  are  erupted  in  good  line,  and  later  one 
or  more  of  them  are  forced  towards  the  outer  or  inner  side  of  the 
arch.  These  conditions  are  not  infrequently  met  with  in  the  lower 
arch,  when,  from  lack  of  harmony  of  the  jaws,  the  upper  incisors 
cause  excessive  inward  pressure  on  the  lower  incisors  and  cuspids,  as 
is  the  case  when  teeth  have  been  extracted  on  the  sides  of  the  upper 
arch,  and  none  from  the  lower.  Again,  when  excessive  and  contin- 
ued mechanical  force  is  apjjlied,  especially  with  an  external  appa- 
ratus, to  reduce  the  prominence  of  the  anterior  upper  arch,  thus 
forcing  the  front  teeth  inward  against  those  of  the  lower  arch,  the 
pressure  is  likely  to  induce  a  saddle-shape  by  crimping  tlie  line  of  the 
lower  arch  in  the  region  of  the  bicuspids.  Sometimes  it  causes 
crimping  of  the  bicuspid  teeth  in  the  upper  arch. 

Prog-nathism. — Prognathism  is  an  abnormal  protrusion  of  the 
jaws.  As  generally  applied  in  orthodontia,  the  term  refers  to  abnor- 
mal protrusions  of  the  lower  jaw.  The  excessive  development  may 
be  hereditary,  or  it  may  be  brought  about  by  acquired  or  local 
causes.  It  is  progressive  in  development,  and  should  usually  be 
placed  under  treatment  early  in  order  to  prevent  the  resultant  facial 
deformity.  In  some  instances  it  is  observable  before  the  eruption 
of  the  permanent  teeth  ;  but  it  may  not  become  apparent  before  the 
tenth  or  twelfth  year,  or  even  until  later  in  life. 

Heredity. — Tlie  tendency  to  prominence  of  the  jaws  is  usually 
transmitted  from  the  parent,  the  characteristic  being  traceable  through 
two  or  more  generations. 

A  marked  prominence  of  the  lower  jaw  of  a  child,  Miss  A.,  aged 


36  ETIOLOGY 

five  years,  is  shown  in  Fig.  1 9.  The  lower  deciduous  incisors  closed 
in  front  of  the  line  of  the  upper  incisors.  In  taking  the  history,  it 
was  learned  that  each  of  the  parents  had  a  prominent  lower  jaw. 
An  examination  was  made,  and  it  w^as  found  that  the  child  was  suf- 
fering from  both  nasal  and  faucial  obstruction.  The  case  was  referred 
to  a  rhinologist,  with  instructions  to  return  with  a  report  from  the 
physician  when  he  had  completed  liis  treatment.     It  was  hoped  that 

the  improvement  of  the  air- 
F^^-  19.  passages,  permitting  more  free 

nasal  breathing,  would  pre- 
vent any  further  excessive  de- 
velopment of  the  lower  jaw. 
Five  years,  however,  elapsed 
before  the  patient  returned. 
The  parents  had  not  had  the 

-^■::^=^:?'rs:=:^ss^^::^^~^^^;:^-::^'!:  obstructious  rcmoved  as  ad- 

'::;^^^ifm'-:^'—^^  vised,  and  a  pronounced  pro- 

trusion of  the  lower  jaw  had 
taken  place.  This  was  accompanied  by  a  partial  arrest  of  develop- 
ment of  the  bones  of  the  upper  arch,  and  the  permanent  upper 
incisors  had  taken  an  irregular  position.  The  parents  were  again 
advised  to  have  the  obstructions  removed ;  the  operation  was  per- 
formed ;  later,  tlie  upper  incisors  were  regulated,  and  a  chin-cap 
applied  in  the  manner  shown  in  Fig.  398,  whicli  reduced  the  prog- 
nathous condition. 

Acquired  Prognathism. — The  prominence  of  the  lower  jaw  when 
not  hereditary  is  termed  acquired  prognathism.  It  results  usually 
from  some  faucial  or  nasal  obstruction  interfering  with  natural  breath- 
ing, as  enlargement  of  the  faucial  tonsils,  adenoid  hypertrophy,  or 
other  obstruction.  When  the  tonsils  are  enlarged,  they  encroach  on 
the  Jiatural  air-passage,  lessening  its  capacity.  In  difficult  breathing 
in  the  early  stages,  before  the  habit  of  mouth-breathing  is  acquired, 
the  patient  usually  makes  an  instinctive  effort  to  improve  the  natural 
passage  for  the  air  by  persistently  forcing  the  lower  jaw  and  tongue 
slightly  forward ;  the  jaws  are  somewhat  separated,  the  lips  closed, 
the  tongue  is  in  its  natural  position  with  the  dorsum  against  the  roof 
of  the  mouth,  the  apex  curving  downward  and  resting  against  the 
inner  surface  of  the  lower  incisors  or  on  their  incisive  edge.  This 
position  is  more  common  during  the  hours  of  sleep.     The  jaw  and 


ACQUIRED  PROGNATHISM  37 

tongue  held  forward  in  this  manner,  while  the  tissues  are  still  in  the 
process  of  development,  encourages  protrusion  of  the  lower  jaw. 

The  more  pronounced  forms  of  acquired  prognathism  are  usually 
accompanied  with  more  or  less  obstruction  in  both  the  naso-  and 
the  oro-pharynx. 

When  there  is  a  certain  degree  of  nasal  or  faucial  obstruction,  or 
both,  mouth-breathing  results.  The  tongue  is  drawn  from  its  natural 
position  in  the  roof  of  the  mouth,  and  settles  in  the  lower  arch  suf- 
ficiently to  form  a  free  air-passage.  The  same  condition  exists  when 
there  is  no  especial  nasal  obstruction,  but  the  faucial  tonsils  are 
enlarged.  They  obstruct  the  air-passage,  and  necessitate  the  pushing 
forward  of  the  tongue,  which  sometimes  protrudes  between  the 
teeth,  especially  at  night,  resting  on  the  incisors  and  interfering  with 
their  natural  eruption,  or  depressing  them  in  tlieir  alveoli,  thus 
causing  lack  of  anterior  occlusion  of  the  teeth.  In  other  instances 
the  tongue  rests  back  of  the  lower  incisors  and  is  forced  farther 
downward  to  increase  the  opening  for  breathing  through  the  mouth. 
When  this  is  continued  for  any  considerable  time,  prognathism 
results.  In  some  cases,  when  the  throat  is  large,  hypertrophied 
tonsils  may  not  interfere  to  this  extent.  Cases  of  receding  lower 
jaw  with  enlarged  tonsils  are  not  uncommon.  The  contraction  of 
the  muscles  to  enlarge  the  air-passage  sometimes  draws  backward 
on  the  jaw  and  prevents  its  anterior  development.  It  is  the  desire 
to  facilitate  free  breathing  that  prompts  the  child  to  throw  the  head 
far  back  during  sleep,  straightening  the  air-passage.  The  continued 
and  combined  action  of  some  of  the  muscles  which  draw  the  lower 
jaw  downward  and  forward,  and  the  natural  tonicity  of  others  draw- 
ing upward  at  the  region  of  the  angle,  tend  to  cause  the  angle  of  the 
jaw  to  become  obtuse.  I  have  seen  several  marked  cases  wherein 
the  change  had  become  so  great  that  the  angle  was  scarcely  distin- 
guishable. From  these  influences  the  jaw  is  often  greatly  lengthened ; 
and  sometimes  its  shape  is  so  considerably  changed  that  only  the 
distal  molar  teeth  occlude,  causing  in  some  extreme  cases  a  separa- 
tion between  the  upper  and  lower  incisors  of  from  one-fourth  to 
three-fourths  of  an  inch,  and  making  it  difficult  to  close  the  lips. 
An  example  of  this  is  seen  in  Fig.  393. 

In  excessive  protrusion  of  the  lower  jaw,  the  lower  incisors  are 
not  infrequently  tipped  inward.  This  is  generally  caused  by  the 
backward  pressure  on  them  of  the  lower  lip. 


38  ETIOLOGY 

Unilateral  prognathism  may  be  brought  about  by  a  local 
cause ;  or  an  acquired,  as  an  enlarged  tonsil  on  one  side.  An  en- 
larged tonsil,  owing  to  its  bulkiness  and  irritation,  has  a  direct 
influence  in  forcing  the  jaw  outward  as  Avell  as  obstructing  the  air- 
passage. 

Local  Causes  of  Prognathism. — Among  local  causes  may  be 
numbered  malocclusion  from  injudicious  extraction  of  permanent 
molar  or  bicuspid  teeth.  The  extraction  of  molars  or  bicuspids  on 
one  side  of  the  upper  arch  not  infrequently  causes  unilateral  j)rog- 
nathism.  The  injudicious  extraction  of  the  deciduous  molar  or 
cuspid  teeth  of  the  upper  arch  permits  the  permanent  upper  incisors 
in  their  process  of  eruption  to  assume  a  position  back  of  the  lower 
incisors.  This  form  of  occlusion  encourages  the  anterior  develop- 
ment of  the  lower  jaw. 

The  improper  eruption  of  the  deciduous  teeth  as  a  result  of  suck- 
ing the  upper  lip  may  occasion  prognathism  (Fig.  35). 

The  sucking  of  the  tongue  is  thought  by  some  Avriters  to  be  a 
cause.  The  tongue  is  doubled  upon  itself,  causing  a  forward  dis- 
placement of  the  lower  jaw\ 

Detrimental  effects  of  the  forward  and  down^vard  pressure  on  the 
jaw  by  the  persistent  sucking  of  the  fingers  have  also  been  observed. 
When,  in  the  adult,  the  upper  incisors  do  not  lap  well  in  front  of 
the  lower  incisors,  sooner  or  later  they  may  occlude  on  their  incisive 
edge  and  become  worn  away,  and  finally  they  are  worn  to  such  an 
extent  as  to  favor  the  lower  incisors  closing  in  front  of  the  upper 
ones,  causing  protrusion  of  the  lower  jaw. 

The  contraction  of  scar  tissue  from  a  severe  burn  about  the  chin 
and  nock  has  resulted  in  prognathism.* 

Hypertrophy  of  the  Tongue. — The  undue  enlargement  of  the 
tongue,  as  from  hypertrophy  or  chronic  congestion,  causes  the  arch 
to  expand,  sometimes  separating  the  teeth  extensively,  usually  affect- 
ing only  the  lower  arch,  but  tlie  upper  arch  also  may  be  involved 
with  the  teeth  tipping  outward.  These  conditions  sometimes  require 
the  contraction  of  the  arch.  I  have  noted  a  number  of  marked 
cases  resulting  from  this  influence.  The  extent  of  the  pressure  on 
the  inner  circle  of  the  arch  from  this  condition  is  sometimes  made 
apparent  by  the  depressions  on  the  lateral  margins  of  the  tongue, 

*  Tomes,  Dental  Sui'Kery,  1887,  p.  176. 


LOCAL  CAUSES  OF  IRREGULARITY  39 

which  appear  in  congestion  accompanying  nervous  disturbances  in 
cases  of  derangement  of  the  digestive  tract. 

Local  Causes  of  Irregularity  of  the  Teeth. — A  tliorough  knowl- 
edge of  the  local  causes  of  irregularities  of  the  teeth  is  important, 
as  many  of  tliese  con(htions  are  the  result  of  neglect  on  the  part  of 
the  patient  or  improper  dental  treatment. 

The  deciduous  teetli  seldom  assume  an  irregular  position.  The 
germs  from  whicli  they  are  developed  are  first  symmetrically  ar- 
ranged in  the  dental  groove,  while  those  of  the  permanent  teeth, 
which  are  larger  and  formed  at  about  the  same  time,  are  necessarily 
located  irregularly  around  the  arch,  and  without  proper  development 
of  the  jaw  they  are  inclincMl  to  erupt  in  an  abnormal  position. 

Premature  Extraction  of  Deciduous  Teeth. — One  of  the  princi- 
pal local  causes  of  irregularity  is  tlie  premature  extraction  or  loss 
of  the  deciduous  teeth.  Tlie  permanent  incisors  and  cuspids  are 
developed  near  to,  or  underneatli,  the  roots  of  the  deciduous  ones. 
They  are  broader  and  larger  in  form,  and  in  the  normal  process  of 
eruption  tlieir  position  causes  them  to  excite  absorption  of  the  roots 
of  the  deciduous  teetli,  and  wedge  their  way  into  place,  increasing 
the  size  of  the  anterior  circle  of  the  arch,  and  they  are  likely  to  be 
erupted  in  an  irregular  position,  if  not  accompanied  witli  an  liarmo- 
nious  development  of  the  maxillary  bone  and  process. 

The  roots  of  the  deciduous  lateral  incisors  are  occasionally  ab- 
sorbed, and  the  teetli  become  loosened  earlier  tlian  they  sliould 
through  the  development  of  the  permanent  central  incisors.  The 
fact  that  the  latter  are  broader  than  their  predecessors  causes  them 
to  impinge  on  the  roots  of  the  deciduous  laterals,  inducing  tlieir  ab- 
sorption, and  consequently  the  permanent  centrals  are  permitted  to 
take  a  position  in  the  space  previously  occupied  by  two  teeth,  a 
deciduous  central  and  a  lateral.  From  this  cause,  at  the  eruption 
of  the  permanent  lateral  incisors,  which  are  naturally  located  a  little 
back  of  the  centrals,  they  are  made  to  assume  an  irregular  position, 
usually  being  forced  to  rest  inside  of  the  circle  of  the  arch. 

In  the  same  manner  the  deciduous  cuspids  are  sometimes  lost 
by  absorption  of  their  roots  excited  by  the  erupting  lateral  incisors 
or  the  first  bicuspids.  This  permits  the  narrowing  of  the  space  that 
should  be  preserved  for  the  perrnanent  cuspids,  and  causes  them  to 
erupt  in  an  abnormal  position  (Fig.  20). 

Tlie  antero-posterior  diameter  of  the  crowns  of   tlie   deciduous 


40 


ETIOLOGY 


molars  is  generally  greater  than  that  of  their  successors,  the  bicus- 
pids. The  combined  measurement  of  the  crowns  of  the  deciduous 
cuspid  and  molars  on  one  side  of  the  arch  is  as  much  as  or  more 
than  that  of  the  permanent  cuspid  and  the  bicuspids,  and  if  the 

deciduous  teeth  are  preserved 
■'^'^'"  ^^'  until  the  time  of  the  eruption 

of  the  permanent  ones,  they 
usually  have  sufficient  room 
for  proper  eruption  in  the 
circle. 

If  either  of  the  deciduous 
molars  or  cuspids  are  lost 
prematurely,  the  first  per- 
manent molar  on  that  side 
moves  forward  in  the  line  of 
the  arch,  and  at  the  same 
time  the  permanent  front 
teeth,  instead  of  being  pushed  forward  by  their  natural  wedging 
during  eruption,  are  crowded  laterally  backward  into  the  space 
which  should  have  been  preserved  for  the  proper  eruption  of  the 
permanent  cuspid  and  the  bicuspids.  When  this  occurs  in  the  upper 
arch,  the  inward  movement 
of  the  incisors  generally  per- 
mits them  to  take  a  posi- 
tion behind  the  lower  ones. 
The  taking  u\)  of  the  space 
on  one  side  of  the  arch  in 
this  manner  occasionally  re- 
sults in  impaction  of  one  or 
more  of  the  bicuspids,  either 
preventing  their  eruption  or 
causing  tliem  to  erupt  on 
the  buccal  or  lingual  side  of 
the  line  of  the  arch.     When 

the  deciduous  cuspid  is  absent,  and  the  permanent  cus\nd  is  not 
well  advanced  in  the  process  of  eruption,  the  bicuspids  usually 
move  forward,  sometimes  to  the  extent  of  (lo.siiig  the;  space.  The 
mesial  surface  of  IIk;  first  bi(iis|)id  then  rests  in  close  ])roximity  to 
the  lateral  incisor,  interfering  with  the  eruption  of   the  permanent 


Fig.  21. 


UNWISE  EXTRACTION  41 

cuspid,  and  causes  it  to  become  too  prominent,  or  to  appear  inside 
of  the  circle. 

Fig.  21  illustrates  a  case  in  which  the  second  upper  deciduous 
molars  were  extracted  too  early.  The  second  bicuspids  not  having 
erupted,  the  first  permanent  molars  during  their  development  gradu- 
ally moved  forward,  taking  up  part  of  the  space.  When  the  upper 
incisors  erupted,  for  lack  of  support  on  the  lateral  sides  of  the  arch, 
they  were  not  crowded  forward  as  should  be,  but  pressed  the  adjoin- 
ing teeth  backward  somewhat  into  the  spaces,  which  finally  resulted 
in  impaction  of  the  second  bicuspids.  At  the  same  time,  from  lack  of 
the  anterior  development  of  the  arch,  the  upper  incisors  closed  back 
of  the  lower  ones,   causing  the  lower  jaw  to  become  prognathous. 

Urfwise  Extraction  of  Permanent  Teeth. — The  inharmonious 
development  of  the  jaws  and  teeth,  as  seen  by  the  crowded  position 
of  the  erupting  permanent  ones  in  young  patients,  often  misleads 
the  inexperienced  practitioner,  and  prompts  him  to  remove  those 
teeth  that  should  be  preserved  to  complete  the  arch,  and  to  cause  a 
good  occlusion  and  harmonize  the  features. 

A  permanent  cuspid  or  a  lateral  incisor  is  not  infrequently  re- 
moved to  lessen  the  crowded  condition  of  the  arch  with  the  hope  of 
correcting  an  irregularity.  If  a  lateral  be  extracted  for  this  purpose, 
it  encourages  the  cuspid,  which  is  of  large  size  and  conical  form,  to 
take  its  place  next  to  the  central  incisor.  The  antero-posterior  di- 
ameter of  the  cuspid  is  more  than  that  of  the  lateral,  and  the  articu- 
lation with  the  opposing  lower  teeth  usually  forces  it  to  take  a  promi- 
nent position.  Its  shape,  also,  is  unsuited  for  this  location,  and  causes 
a  conspicuous  deformity.  Therefore  the  lateral  incisors  should  gen- 
erally be  preserved. 

When  the  cuspid  is  too  prominent,  with  insufficient  space,  or 
when  it  erupts  inside  of  the  circle  of  the  arch,  it  is  sometimes 
extracted  with  the  intention  of  correcting  the  irregularity.  The 
shape  of  the  cuspid  and  the  prominence  of  its  root  adds  character 
to  the  face,  and  it  should  not  be  extracted  when  avoidable,  as  after 
its  removal  the  process  that  covers  the  root  becomes  absorbed  ;  this 
results,  usually,  in  giving  a  flattened  and  unnatural  expression  to  the 
features  in  the  region  of  the  canine  eminence.  When  the  teeth  are 
crowded  and  the  removal  of  a  tooth  in  this  location  is  necessary, 
it  is  usually  the  better  practice  to  extract  a  bicuspid. 

For  lessening  the  prominent  efi'ect  of  tlie  superior  arch,  occasionally 


42  ETIOLOGY 

a  molar  or  bicuspid  is  removed,  and  a  year  or  more  later  it  is  found 
that  the  lower  jaw  has  lengthened  and  broadened  without  a  corre- 
sponding development  of  the  upper  jaw,  causing  the  upper  lip  to 
have  a  sunken  appearance  difficult  to  deal  with.  It  cannot  be 
remedied  except  by  contracting  the  size  of  the  lower  arch  after 
extraction,  or  by  the  moving  forward  bodily  of  the  incisors  and 
cuspids  of  the  upper  arch.  Again,  the  family  type  should  be  care- 
fully considered  before  extracting,  any  undue  prominence  of  the 
cheek-bones  and  the  nose  being  noted.  These  parts  do  not  come 
to  complete  development  until  the  full  age  of  maturity,  and  if  the 
child  inherits  a  large  nose  and  prominent  cheek-bones,  and  some  of 
the  teeth  have  been  unwisely  removed,  the  nose  and  cheeks  will 
be  likely  to  appear  unduly  conspicuous.  Probably  there  is  no  part 
of  the  body  which  exhibits  more  strongly  the  influence  of  heredity 
than  the  nose,  ears,  and  cheek-bones,  but  their  characteristics  are 
not  fully  shown  until  the  time  of  maturity.  The  foregoing  points 
cannot  always  be  determined  by  a  simple  examination  of  the  patient. 
However,  if  the  prominence  of  the  upper  arch  is  known  to  be  heredi- 
tary, the  correction  should  be  begun  early.  In  such  a  case,  w^hen 
necessary,  the  first  bicuspids  are  extracted.  In  some  instances,  to 
retard  the  anterior  development,  when  there  is  tendency  to  extreme 
protrusion,  the  bicuspids  should  be  extracted  before  they  are  fully 
developed,  removing  the  first  deciduous  molars,  and  if  necessary 
some  of  the  alveolar  process.  On  the  other  hand,  the  injudicious 
early  extraction  of  the  first  lower  •permanent  molars,  before  the  erup- 
tion of  all  of  the  teeth  of  the  arch,  removes  the  lateral  support  of  the 
jaw  and  interferes  with  its  anterior  development,  while  the  normal 
growth  of  the  upper  arch  continues,  bringing  about  an  apparent 
protrusion  of  the  jaw,  a  condition  tliat  would  not  have  existed  had 
the  lower  molars  been  preserved. 

It  is  not  an  uncommon  practice  among  certain  dentists  to  extract 
the  first  permanent  molars  with  the  intention  of  relieving  a  crowded 
condition,  and  lessening  the  tendency  to  decay  among  the  remaining 
teeth,  by  permitting  spaces  to  occur  between  them.  This  procedure 
usually  proves  to  be  a  mistake ;  in  but  few  instances  are  the  con- 
ditions such  as  to  require  their  removal.  The  first  permanent 
molars  are  the  most  important  (A'  any  of  the  grinding  teeth,  and 
should  be  jjreserved,  as  they  help  to  secure  the  proper  occlusion  and 
relationship  of  the  jaws.     The  poor  structure  and  early  decay  of 


TOO  LONG  RETEXTIOX  OF  DECIDUOUS  TEETH       43 

these  teeth  sometimes  necessitates  their  extraction,  Jjut  when  they 
are  removed  the  anterior  teetli  do  not  usually  se})arate  and  move 
backward  into  the  spaces  witliout  mechanical  interference  ;  but  rather 
the  second,  and  later  the  third,  molars  tip  forward,  with  only  the  dis- 
tal part  of  their  crowns  touching  their  antagonists,  bringing  about 
an  unnatural  and  objectionable  occlusion.  Again,  the  extraction  of 
the  first  permanent  molars  before  the  eruption  of  all  of  the  teeth 
interferes  with  the  anterior  development  of  the  jaw,  resulting  in  its 
sliortening  and  the  weakening  of  the  support  of  adjoining  teeth  by 
the  loss  of  the  intervening  alveoli. 

Too  Long  Retention  of  Deciduous  Teeth. — The  permanent  teeth 
in  their  process  of  eruption  are  occasionally  directed  into  an  abnor- 
mal position  by  deciduous  teeth  that  have  not  become  loosened  by 
absorption  and  have  been  retained  too  long.  The  permanent  incisors, 
cuspids,  and  bicuspids  are  sometimes  thus  made  irregular,  the  ab- 
sorption of  the  deciduous  tooth  in  some  instances  evidently  taking 
place  on  one  side  of  the  root  only,  while  the  pressure  of  the  other 
or  miabsorbed  part  is  sufficient  gradually  to  direct  the  erupting  tooth 
inward  or  outward  from  the  natural  circle  of  the  arch  according  to 
its  location.  This  is  especially  apparent  when  the  deciduous  tooth 
has  become  devitalized,  which  retards  its  natural  absorption.  The 
simple  removal  of  the  unabsorbed  portion  of  the  root  is  usually 
sufficient  to  permit  the  permanent  tooth  to  take  a  correct  position, 
provided  there  is  room  for  its  eruption. 

Supernumerary  Teeth. — Teetli  exceeding  the  usual  number,  and 
not  properly  belonging  to  eitlier  dentition,  are  classed  as  super- 
numerary teeth.  Their  crowns  may  be  conical  in  form,  or  shaped  so 
like  the  adjacent  teeth  as  to  make  it  impossible  to  determine  wliich 
are  the  supernumerary.  They  may  appear  in  different  locations, 
sometimes  erupting  by  the  side,  but  most  commonly  between  other 
teeth,  especially  between  the  central  incisors.  The  excess  of  tlie 
normal  number  of  teeth  usually  causes  a  crowded  condition,  in- 
terfering with  the  symmetry  of  the  arch.  When  the  intruder  is 
conically  shaped,  the  adjacent  teeth  are  more  liable  to  be  deflected 
or  rotated  into  irregular  positions.  When  found  with  the  molars  or 
bicuspids  they  are  generally  small,  and  located  on  the  buccal  or 
lingual  side,  or  back  of  the  last  molar.  Supernumerary  teeth  are 
not  uncommonly  found  with  the  deciduous  set,  principally  among 
the  lower  incisors  ;  and  somethnes  they  coalesce. 


44 


ETIOLOGY 


Irregularities  that  arise  from  the  presence  of  supernumerary  teeth 
are  generally  improved  by  their  extraction. 

Fig.  22  illustrates  the  case  of  a  boy,  aged  nine  years,  with  two 
irregularly  shaped  supernumerary  teeth  back  of  and  in  the  position 


Fig.  22. 


of  the  central  incisors,  forcing  the  incisors  to  take  a  very  prominent 
position,  with  a  broad  space  between  them. 

In  Fig.  23  is  seen  a  similar  case,  the  two  supernumerary  teeth 
being  in  front  of  the  central  incisors,  with  the  other  teeth  in  the 


Fk;.  23. 


anterior  part  of  the  arch  much  crowded.     The  supernumerary  teeth 
were  extracted,  and  several  months  later  the  teeth  of  the  arch  had 


SUPERNUMERARY  TEETH— ANOMALIES 


45 


assumed  the  position  shown  in  Fig.  24,  there  being  no  mechanical 
interference. 

Fig.  24. 


Fig.  25  shows  an  interesting  case  with  four  well-formed  upper 
lateral  incisors.  An  irregularity  of  the  teeth  was  brought  about  by 
the  presence  of  the  supernumerary  laterals,  one  having  erupted  in- 


FiG.  25. 


side  of  the  natural  alignment  of  the  arch,  and  the  other  in  the  posi- 
tion of  the  right  upper  cuspid,  causing  it  to  become  too  prominent. 

Anomalies. — In  this  connection  several  cuts  Avill  be  presented 
showing  anomalies  which  are  not  so  uncommon  as  to  require  special 
comment,  but  are  yet  of  interest. 


46 


ETIOLOGY 


Fig.  26  illustrates  a  case  with  the  position  of  the  permanent  lateral 
incisors  and  cuspids  reversed, — that  is,  the  cuspids  located  next  to 


Fig.  26. 


the  central  incisors,  and  the  lateral  incisors  back  of  them  and  in 
front  of  the  first  bicuspids.  The  alignment  of  the  teeth  was  good, 
but  their  appearance  was  marred  by  the  transposition. 

In  Fig.  27  is  seen  the  natural  position  of  the   first   letl  superior 
bicuspid  and  cuspid  reversed.    The  lateral  incisors  were  not  erupted. 

Fig.  27. 


The  right  cuspid  had  taken  a  po.sition  near  the  central  incisor,  and 
the  first  left  bicuspid  had  moved  forward  towards  the  incisor,  with 
the  cuspid  between  il  and  the  second  bicuspid. 

Fig.   28  illustrah's  a  lower  arch    in   which   there  were  only  two 
incisors  in  place  of  four.    They  appeared  like  perfectly  shaped  upper 


TRREGTTLARITIES   FTJOM    ACCIDENT 


47 


central  incisors,  and  the  two  were  broad  enoug-li  to  fill  the  natural 
space  between  the  cuspids.  The  number  of  deciduous  incisors  was 
not  ascertained. 


Irregularities  caused  by  Accident. — The  following  cuts  illustrate 
interesting  cases  resulting  from  accident.     In  Fig.  29   the  alveolar 

Fig.  29. 


process  was  injured  before  the  eruption  of  the  permanent  teeth,  and 
when  they  appeared  they  were  considerably  separated  from  the 
median  line.  A  central,  lateral,  cuspid,  and  the  bicuspids  were 
bunched  together  on  the  left  side,  and  a  central,  lateral,  and  cuspid 
on  the  right  side,  the  rest  of  the  teeth  being  in  their  usual  positions. 


48 


ETIOLOGY 


The  process  at  the  median  hne  was  full  although  irregular,  there 
being  no  appearance  of  a  cleft. 

The  three  succeeding  figures  are  cuts  from  models  presented  by  a 
prominent  practitioner,  who  considered  the  conditions  the  result  of 
an  accident,  or  of  the  premature  extraction  of  the  deciduous  teeth. 
After  the  loss  of  the  six  anterior  deciduous  teeth,  the  permanent 
ones  erupted  as  seen  in  Fig.  30.     The  roots  of  the  central  incisors 

Fig.  30. 


were  diverging,  causing  a  broad  V-shaped  space  between  their  crowns, 
and  the  lateral  incisors  had  taken  a  position  back  of  them  and  inside 
of  the  circle  of  the  arch.     It  was  not  thought  advisable  to  attempt 

Fig.  32. 


their  regulation.  Owing  to  tlu;  unpleasant  appearance  the  central 
incisors  were  extracted,  and  the  roots  were  found  to  be  bent  towards 
each  other  as  seen  in  Fif'.  31.     About  eight  weeks  after  the  extrac- 


INJURIOUS  HABITS— THUMB-SUCKING  49 

tion  of  these  teeth,  two  supernumerary  teeth  with  imperfect  surfaces 
were  erupted  in  place  of  the  incisors,  the  other  teeth  remaining  in 
the  same  position  (Fig.  32). 

Injurious  Habits. — During  tiic  lime  of  the  eruption  of  the  teeth 
the  jaw  and  alveolar  process  are  developing,  and  are  easily  changed 
in  their  contours.  It  is  while  the  tissues  are  in  this  formative  con- 
dition that  the  evil  habit  of  sucking  the  thumb,  finger,  lips,  tongue,  or 
cheek  is  usually  begun,  and  when  continued,  it  is  liable  to  cause  a 
marked  influence  on  the  future  shape  of  the  jaws  and  position  of 
the  teeth.  These  habits,  if  not  corrected,  are  in  some  instances  con- 
tinued after  the  eruption  of  the  permanent  teeth. 

Sucking  the  Tfmmb. — The  persistent  pressure  of  the  tongue  against 
the  thumb  or  the  fingers  as  they  are  placed  in  the  mouth  imparts  a 
corresponding  pressure  forward  and  upward  against  the  inner  part 
of  the  anterior  superior  arcli  or  intermaxillary  division,  which  grad- 
ually yields,  bringing  about  an  abnormal  anterior  development.  The 
natural  closure  of  the  jaws  against  the  thumb  or  fingers  while  they 
are  placed  in  the  mouth  in  this  manner,  induces  additional  pressure 
on  the  teeth,  forcing  the  lower  incisors  inward,  while  at  the  same 
tune  the  upper  ones  are  moved  outward.  This  often  causes  a 
considerable  space  to  intervene  between  the  upper  and  lower 
incisors,  but  the  principal  permanent  irregularity  that  results  from 
this  habit  is  from  its  continuance  after  the  eruption  of  the  permanent 
teeth. 

Fig.  33  illustrates  the  position  of  the  deciduous  teeth  of  a  boy 
aged  five  years.     The  upper  incisors  had  become  so  prominent  that 

Fig.  33. 


they  projected   outward   over  the  lower  lip,  and  the  anterior  line 
described  by  the  lower  incisors  was  very  nmch  flattened  by  being 

4 


50  ETIOLOGY 

pressed  inward.  The  figure  illustrates  a  typical  irregularity,  caused 
by  sucking  the  two  first  fingers  of  the  right  hand. 

Some  time  since  I  was  called  upon  to  prescribe  for  the  breaking 
up  of  a  persistent  habit  of  thumb-sucking  in  a  girl  aged  thirteen 
years.  In  this  case  the  lower  jaw  receded  and  the  upper  incisors 
had  become  very  prominent.  The  parents  stated  that  they  had  not 
attempted  to  correct  the  habit  until  after  the  eruption  of  the  anterior 
permanent  teeth  ;  then,  realizing  that  a  deformity  was  being  brought 
about,  they  had  for  several  years  sought  professional  aid,  both  from 
physicians  and  dentists,  but  none  of  the  methods  reconmiended  had 
proved  successful.  The  patient  was  unusually  intelligent,  but  when- 
ever she  became  absorbed  in  thought,  either  at  home  or  on  the  street, 
she  would  resort  to  the  habit,  and  it  had  become  extremely  embar- 
rassing to  her  and  to  her  people.     (See  Fig.  281.) 

Sucking  or  biting  the  Lips. — The  habit  of  sucking  the  lip  is  usually 
begun  at  about  the  time  the  child  is  being  weaned,  although  in  some 
instances  it  is  taken  up  in  early  infancy  and  is  generally  continued 
after  the  eruption  of  the  permanent  teeth.  The  lower  lip  is  the 
more  frequently  the  sufferer ;  it  is  drawn  upward  over  the  lower 
incisors,  tipping  them  backward,  and  in  some  cases  these  teeth  are 
depressed  in  their  sockets.  At  the  same  time  the  upper  incisors 
through  their  forcible  contact  with  the  front  of  the  lip,  are  pressed 
outward  and  may  be  lengthened.  Fig.  34  shows  the  features  of  a 
girl  aged  twelve,  who  had  practised  the  habit  of  sucking  the  lower  lip 
at  niglit  and  almost  continuously  during  the  day  from  infancy,  causing 
the  upper  incisors  to  project  considerably  over  the  lower  lip,  those 
on  the  left  side  being  especially  prominent.  On  examination  it  was 
found  that  the  deformity  was  caused  by  the  lip  being  draw^n  more 
towards  the  left  side  in  the  process  of  sucking.  The  evil  habit  was 
overcome  by  moving  the  incisors  inward  to  tlieir  proper  position 
and  by  the  special  efforts  of  the  i)alient  to  keep  the  lip  in  front  of  them. 

Marked  cases  of  irregularity  resulting  from  sucking  the  upper  lip 
have  been  presented,  although  the  habit  is  not  considered  a  common 
one.  Fig.  35  shows  the  case  of  a  girl,  aged  two  years  and  ten 
nionlhs,  in  which  an  irregularity  of  the  deciduous  set  \vas  caused  by 
this  liabit.  The  upper  incisoi's  and  cuspids  were  made  to  close  back 
of  those  in  (lie  lower  anh.  The  irregularity  was  corrected  as  seen 
in  Fig.  185. 

The  sucking  of  the  ui)per  lip  at  the  time  of  the  shedding  of  the 


Fig.  34. 


LIP-BITING— TONGUE-SUCKING 


51 


Fig.  35. 


deciduous  teeth  and  the  eruption  of  the  permanent  ones  is  especially 
liable  to  cause  irregularity  of  the  incisors.  The  permanent  upper 
teeth  are  directed  inward  by  the 
pressure  and  are  made  to  close  back 
of  those  of  the  lower  arch.  This, 
and  the  curling  in  of  the  lips,  suck- 
ing, or  biting  both  of  them  at  the 
same  time,  is  not  an  unconmion 
cause  of  depression  of  the  anterior 
teeth  in  their  alveoli,  producing  lack 
of  anterior  occlusion. 

Tongue  -  Sucking.  —  When      t  h  e 
tongue     is    sucked,    it    is    generally 

doubled  upon  itself.  This  broadens  it  laterally,  and,  if  the  habit  is 
continued,  it  may  influence  the  position  of  the  teeth  by  pressing  them 
outward  in  the  region  of  the  middle  and  distal  part  of  the  arch. 
Sucking  the  cheeks  has  a  reverse  tendency,  pressing  the  anterior 
molars  and  bicuspids  inward,  and  sometimes  depressing  them  in 
their  alveoli,  thus  causing  lack  of  lateral  occlusion. 

I  am  convinced  that  these  habits,  as  deforming  factors,  are  more 
common  than  is  generally  supposed,  and  deserve  careful  considera- 
tion. 

Pyorrhoea  Alveolaris  causing-  Irregularity  of  the  Teeth. — 
Irregularity  resulting  from  pyorrhoea  alveolaris  is  common.  The 
alveolar  process  is  usually  more  or  less  wasted  away  and  the  teeth 
elevated.  Before  the  correction  of  the  irregularity  is  attempted 
the  disease  should  be  stayed  by  removing  the  cause  as  far  as  may 
be,  and  when  necessary  by  continuing  with  both  systemic  and  local 
treatment  to  prevent  its  recurrence. 

If  the  teeth  have  become  elevated,  they  should  not  be  pressed 
more  deeply  into  their  sockets,  as  that  would  aggravate  the  existing 
tendency  to  congestion  by  increasing  the  depth  of  the  pockets.  The 
occluding  surfaces  of  the  teeth  should  rather  be  dressed  down  by 
grinding  with  a  corundum  stone  from  time  to  time  as  required, 
destroying  the  pulp  if  necessary. 

The  application  of  a  proper  regulating  appliance  in  these  cases 
often  improves  the  usefulness  of  the  teeth,  even  in  aggravated  con- 
ditions, and  without  its  application  the  irregularity  is  likely  to  increase. 
The  regulating  force  should  be  applied  gradually,  and  the  teeth  should 


52  ETIOLOGY 

be  well  supported  for  a  considerable  length  of  time.  In  some  cases 
a  permanent  retainer  is  required ;  in  others,  the  retaining  appliance 
can  be  worn  at  night  only. 

In  practice  it  is  sometimes  difficult  to  classify  satisfactorily  the 
cause  of  an  irregularity  from  the  history  obtainable  and  the  exami- 
nation of  the  case  presented,  as  irregularities  depend  upon  varied 
influences.  A  knowledge  of  the  etiology  of  irregularities  of  the  teeth 
is  necessary  to  enable  one  to  diagnose  and  to  anticipate  the  condi- 
tions, to  determine  the  advantages  to  be  gained  by  an  operation,  and 
to  be  able  to  judge  from  the  tendencies  how  long  the  teeth  will  need 
to  be  retained. 


CHAPTER   II 
THE  ALVEOLAR  PROCESS 

The  alveolar  processes  are  the  dental  margins  of  tlie  jaws  in 
•which  the  teeth  are  set.  They  consist  of  an  outer  cortical  layer  or 
plate  of  bone,  connected  with  a  cancellate  tissue,  which  is  developed 
from  the  outer  margins  of  the  upper  and  lower  maxilla,  and  follows 
their  curves.  They  envelop  the  teeth  and  grow  with  them  for  their 
support.  In  addition  to  these  cortical  layers  of  the  process,  which 
are  of  dense  material,  there  is  a  thin  lamina  of  similar  structure 
that  surrounds  the  teeth  and  their  roots  as  they  develop,  forming 
the  alveoli.  This  contains  many  vascular  openings  for  the  vessels 
of  nutrition  and  the  nerves. 

The  cellular  or  cancellate  tissue  forms  the  major  part  of  the 
alveolar  process.  It  is  built  around  the  lamina  of  the  alveoli,  form- 
ing the  septa  which  connect  the  bony  plates  and  separate  the  teeth. 
(Owing  to  the  great  vascularity  of  these  tissues,  they  are  readily  ab- 
sorbed.) 

As  the  teeth  progress  in  their  development,  the  thin  covering  of 
process  over  their  crowns  is  absorbed,  permitting  their  eruption, 
and  when  the  teeth  are  fully  erupted  the  process  is  developed 
around  the  necks  of  the  teeth,  and  each  alveolus  is  made  to  invest 
closely  the  fang  contained  within  it,  leaving  space  between  the  walls 
of  the  alveolus  and  the  fang  for  the  thin  peridental  membrcme  which 
connects  them.  This  membrane  is  highly  vascular,  and  furnishes 
nutrition  for  the  tooth.  At  the  neck  and  towards  the  apex  of  the 
root  it  is  rich  in  nerve-tissue,  and  is  the  organ  for  the  sense  of  touch 
for  the  tooth. 

Teeth  are  developed  from  the  mucous  membrane  of  the  mouth. 
The  crypts  are  formed  in  the  dental  groove,  which  is  of  true  bone 
and  process.  When  the  teeth  are  fully  formed  and  erupted,  the 
roots  are  surrounded  with  alveolar  process,  the  alveoli  extending 
into  the  jaw.  The  depth  of  this  penetration  is  variable  in  different 
persons,  and  in  different  parts  of  the  same  jaw. 

The  purpose  of  the  alveolar  process  is  to  protect  the  teeth  through 
their  formative  stage,  and  later  to  support  them.     During  the  erup- 

53 


54  THE   ALVEOLAR  PROCESS 

tion  of  the  teeth  the  process  follows  and  surrounds  their  roots  in 
almost  any  position  they  may  assume,  and  when  the  teeth  are  re- 
moved, there  being  no  further  use  for  it,  it  is  gradually  absorbed, 
leaving  a  smoothly  contoured  surface. 

The  application  of  force  to  the  teeth,  when  continued  and  steady, 
causes  absorption  of  the  bone  in  advance  of  the  moving  tooth ; 
while  the  space  that  is  left  by  the  movement  on  the  opposite  side  of 
the  tooth  is  gradually  built  in  by  a  redeposit  of  bone. 

The  bone  and  process  covering  the  roots  of  the  teeth  is  much 
thicker  in  some  parts  of  the  arch  than  in  others,  and  not  uncom- 
monly proves  an  annoying  barrier  in  operations,  such  as  expanding 
the  upper  arch.  The  malar  process  usually  projects  downward 
over  the  sides  of  the  roots  of  the  molars  and  bicuspids,  causing  them 
to  be  elongated  as  they  are  moved  outward.  The  thickened  process 
back  of  the  upper  and  lower  incisors  adds  to  the  difficulty  of  their 
inward  movement. 


CHAPTER  III 


OCCLUSION    AND    ARTICULATION 

The  occlusion  of  the  teeth  is  the  relative  position  of  the  upper  and 
lower  teeth  as  they  naturally  close  together,  with  the  cusps  of  the 
teeth  of  one  arch  resting  in  the  sulci  of  those  of  the  opposite  arch, 
although  the  upper  and  lower  teeth  do  not  normally  remain  in 
contact  even  when  the  lips  are  closed. 

Articulation  is  the  closure  of  the  upper  and  lower  teeth  together 
in  any  of  the  normal  positions,  as  in  general  occlusion,  or  the  placing 
of  the  upper  and  lower  incisors  edge  to  edge. 

In  cases  presented  for  treatment,  the  manner  of  the  occlusion  of 
the  teeth  should  be  carefully  noted  by  the  operator,  and  mentally 
compared  with  the  normal  or  ideal  type  of  jaws. 

In  the  correction  of  irregularities  it  is  necessary  to  have  an  under- 
standing of  the  accepted  ideal  type,  and  to  imitate  it  as  far  as  may  be, 

adapting  it  to  the  special 

^      ^  ^  Pig.  30. 

cast  of  features  presented 

for  the    improvement    of 

the  occlusion  and  of  facial 

contour. 

The  shapes  and  arrange- 
ment of  the  teeth  admi- 
rably adapt  them  for  the 
purposes  for  which  they 
were  intended. — the  in- 
cising and  trituration  of 
food, — while  their  various 
sizes,   length,  width,   and 

contour,  when  symmetrically  developed   in   the  different  types,  give 
harmony  and  beauty  to  the  features. 

Fig.  36  is  intended  to  illustrate  a  normal  occlusion  of  the  teeth. 
The  natural  arch  forms  a  graceful  curve,  similar  to  a  semi-ellipse, 
with  the  teeth  symmetrically  arranged  one  next  the  other.  The  part 
of  the  curve  formed  by  the  incisors  and  bicuspids  is  slightly  flattened, 
with  a  corresponding  prominence  at  the  location  of  the  cuspids. 

55 


56  OCCLUSION   AND   ARTICULATION 

The  upper  arch  is  sUghtly  larger  than  the  lower,  especially  in  its 
anterior  part ;  the  incisors  and  cuspids  are  a  little  broader,  and 
occlude  in  front  of  the  lower  teeth,  covering  about  one-third  of  their 
crowns.  While  the  anterior  part  of  the  lower  arch  is  a  little  nar- 
rower than  the  upper,  it  bends  outward  in  the  region  of  the  third 
and  second  molars,  being  broader  than  the  upper  arch,  the  teeth 
tipping  slightly  inward. 

The  upper  central  incisor  is  broader  than  the  lower  central  incisor, 
and  occludes  with  it  and  one-half  of  the  lateral.  This  causes  the 
upper  lateral  incisor  to  articulate  with  the  lower  lateral  incisor  and 
cuspid,  and  the  morsal  surface  of  the  upper  cuspid  with  that  of  the 
lower  cuspid  and  first  bicuspid,  the  cusps  of  the  upper  lirst  bicuspid 
with  the  lower  first  and  second  bicuspids,  the  upper  second  bicuspid 
with  the  lower  second  bicuspid  and  first  molar,  the  upper  first  molar 
with  the  lower  first  and  second  molars,  the  upper  second  molar  with 
the  lower  second  and  third  molars,  and  the  upper  third  molar  with 
the  lower  third  molar,  the  crown  of  the  upper  third  molar  being 
usually  smaller  than  the  lower. 

When  all  of  the  teeth  of  the  upper  and  lower  arch  rest  in  occlusal 
contact,  it  is  termed  normal  or  full  occlusion.  When,  as  normally, 
the  upper  incisors  close  in  front  of  the  lower,  the  upper  incisors  are  in 
a  labial  occlusion  and  the  lo\ver  incisors  in  a  lingual  occlusion. 
When  the  upper  incisors  close  back  of  the  lower,  they  have  a  lingual 
occlusion  and  the  lower  incisors  a  labial  occlusion.  When  only  the 
incisors  of  the  upper  and  the  lower  arch  touch  in  occlusion,  it  is  termed 
anterior  occlusion,  or  lack  of  posterior  occlusion.  When  only  the 
distal  upper  and  lower  molars,  or  the  molars  and  bicuspids,  rest  in 
contact,  it  is  termed  distal  occlusion,  or  lack  of  anterior  occlusion. 
When  the  upper  and  lower  molars  and  bicuspids  rest  in  contact  only 
on  one  side  of  the  arch,  it  is  termed  unilateral  occlusion. 


CHAPTER    IV 

EXAMINATION    OF    PATIENTS— RECORD  OF  CASES— IMPRESSIONS- 
MODELS    OF   TEETH— CAST    OF   FEATURES 

The  human  face  is  said  to  be  the  mirror  of  the  soul.  It  reflects 
the  intelligence  of  the  mind  and  betrays  its  passing  impulses.  The 
first  thing  that  strikes  us  favorably  in  a  face  is  exactness  of  propor- 
tion, then  harmony  of  the  features.  When  a  case  is  presented  for 
the  regulation  of  the  teeth,  it  is  important  that  the  contour  of  the 
features  be  studied  before  the  mouth  is  examined  or  models  are 
made.  Careful  note  should  be  taken  of  the  apparent  changes 
required ;  these  should  accord  with  the  type  and  temperament  of 
the  patient,  whether  w^ell  nourished  or  developed,  the  profile,  in- 
cluding the  size  of  the  nose  and  the  orifices,  the  width  between  the 
alae  nasi,  the  prominence  of  the  cheek-bones,  and  the  fulness  or 
recession  in  the  region  of  the  upper  lip.  The  relative  position  of 
the  chin  to  the  forehead  should  be  noted  to  determine  where  the 
deformity  is  situated,  and  wiiether  the  upper  or  lower  arch  should 
be  made  more  or  less  prominent.  The  features  should  be  studied 
both  in  repose  and  when  animated,  especially  when  laughing.  In 
extreme  upper  protrusion,  the  lower  jaw  sometimes  rests  forward  in 
occlusion,  and  in  laughing  the  contraction  of  the  muscles  forces  the 
lower  jaw  backward  again  into  the  normal  temporo-maxillary  articu- 
lation. This  change  always  causes  the  upper  teeth  to  appear  more 
conspicuous. 

History  of  the  Case. — It  is  essential  that  a  correct  diagnosis 
of  the  conditions  should  be  arrived  at  before  beginning  an  operation, 
and,  if  the  case  is  a  complicated  one,  it  is  usually  necessary  to  have 
a  knowledge  of  the  hereditary  proclivities.  Such  information  should 
be  gained  from  the  parent  or  guardian.  It  should  state  the  age ; 
w^hether  the  patient  has  had  any  bad  hal^its,  such  as  sucking  the 
cheek,  tongue,  lip,  fingers,  or  tlmmb,  and  how  long  continued ;  if 
the  patient  is  a  mouth-breather,  and  whether  continuously,  or  only 
during  the  hours  of  sleep,  or  when  suffering  from  colds ;  and  any 
other  points  that  may  seem  to  be  necessary  for  obtaining  a  complete 
understanding  of  the  case. 

57 


58  EXAMIXATIOX   OF  PATIENTS— RECORDS 

Physical  Examination. — This  consists  of — 

First,  examination  of  the  mouth,  including  the  occlusion,  position, 
and  size  of  the  teeth,  the  form  of  the  arch,  the  form  and  size  of  the 
jaws,  the  size  of  the  tongue. 

Second,  examination  of  the  throat  and  posterior  nares,  to  deter- 
mine whether  they  are  constricted,  or  if  the  tonsils  are  abnormally 
developed,  and  whether  adenoid  growths  are  present. 

Third,  examination  of  the  nose,  to  determine  the  size  of  the  aper- 
tures, condition  of  the  septum,  whether  the  vomer  or  cartilage  is 
deflected,  whether  there  is  congestion  of  the  mucous  membrane  or 
disease  of  the  turbinated  bones,  or  any  asymmetry  of  the  parts.  To 
complete  the  examination,  models  of  the  teeth,  made  from  impres- 
sions of  both  the  upper  and  lower  arch  should  be  prepared  for  further 
study  of  the  case. 

Record. — When  a  case  has  been  fully  examined  and  considered, 
and  an  operation  is  decided  on,  a  full  record  of  the  conditions  should 
be  made,  its  character  depending  much  upon  tlie  changes  that  are  to 
be  brought  about ;  for  the  more  simple  cases  make  only  a  written 
record,  including  the  especial  characteristics,  the  age  and  sex,  and 
preserve  models  of  the  teeth.  In  cases  where  marked  changes  in 
the  features  are  to  be  made,  the  record  should  be  more  com- 
plete, either  by  taking  measurements  of  the  face  with  a  profilometer 
or  goniometer  or  a  record-card,  traced  from  a  soft  wire  shaped  to  the 
features ;  or  by  making  a  plaster  cast  of  the  features ;  or  by  taking 
a  photograph — in  special  cases  a  skiagraph  to  show  the  position  of  the 
roots  of  the  teeth.  It  is  also  advisable  to  preserve  a  written  record 
and  models  of  the  teeth  of  cases  where  the  regulation  is  not  un- 
dertaken.    They  may  prove  of  value  at  some  future  time. 

Impressions. — The  taking  of  impressions  of  the  teeth  is  so  gener- 
ally understood  that  only  some  of  the  more  important  features  will 
be  described.  For  regulating  purposes  it  is  very  necessary  that  an 
exact  model  of  the  teeth  should  be  obtained,  including  the  roof  of 
the  mouth  and  accurate  markings  of  the  ruga;  and  the  contour  of  the 
gum.  The  materials  adapted  for  this  purpose  are  impression  com- 
positions, plaster  of  Paris,  and  modelling  compound.  Gutta-percha, 
wax,  and  clay  have  been  used. 

Tlu;  jjroce.ss  of  taking  the  impressions  should  be  sufficiently  ex- 
[)lained  to  the  patient  to  relieve  him  of  any  fear,  and  the  necessity 
of  breathing  forcibly  and   continuously  through  tlie  nose  with  the 


IMPRESSIONS  59 

mouth  01)011,  to  prevent  any  tendency  to  nausea  or  strangling,  should 
be  shown.  Breathing  through  the  mouth  will  increase  the  difficulty, 
excepting  where  the  head  is  thrown  far  forward. 

In  order  to  take  a  good  impression,  the  iinpression-tray  should 
be  well  adapted  to  the  arch,  not  bearing  too  heavily  on  any  of  the 
parts,  and  no  more  than  a  sufficient  amount  of  the  plastic  material 
should  be  used. 

In  taking  a  plaster  impression,  it  should  be  allowed  to  become 
rather  hard  before  being  removed  from  the  mouth.  If  the  impres- 
sion is  broken  in  removing,  the  parts  should  be  carefully  readjusted 
in  the  tray  and  united  before  running  the  model.  Sometimes  it  is 
advisable  to  form  a  close-fitting  impression-tray  by  first  taking  an 
impression  in  softened  wax.  After  its  removal  the  openings  made  by 
the  teeth  should  be  enlarged  by  cutting  away  some  of  the  wax.  The 
wax  impression  is  then  used  as  a  tray,  with  which  an  impression  is 
taken  in  the  usual  manner.  With  the  latter  method  the  plaster  is 
generally  more  easily  removed  from  the  model. 

Impressions  of  irregular  teeth  for  the  purpose  of  making  regu- 
lating appliances  should  be  taken  in  plaster  of  Paris,  at  least  until 
one  has,  through  trial,  become  sufficiently  expert  to  take  them 
accurately  with  some  of  the  modelling  compounds.  When  the 
impression  is  taken  in  compound,  the  surface  of  the  model  is 
generally  smoother  than  when  taken  in  plaster ;  it  is  quickly  made, 
and  the  procedure  is  more  agreeable  to  the  patient.  The  im- 
pression should  be  held  firmly  in  position,  and  hardened  as  quickly  as 
possible  by  the  application  of  ice-water,  by  means  of  napkins  about 
two  inches  square,  folded  and  moistened ;  or  small  pieces  of  ice 
folded  in  napkins  may  be  used,  or  cold  water  applied  by  a  syringe, 
tipping  the  head  forward.  Care  should  be  exercised  not  to  remove 
the  impression  until  all  of  the  compound  is  well  hardened  ;  the 
thicker  parts  cool  more  slowly. 

When  the  teeth  are  long,  and  there  is  danger  of  the  compound  drag- 
ging while  being  removed,  before  inserting  the  impression  material 
a  quantity  of  French  chalk  should  be  hastily  and  thoroughly  rubbed 
over  its  surface  to  prevent  it  from  clinging  to  the  teeth.  If  there  are 
large  undercuts  between  or  cavities  in  the  teeth  that  are  of  such 
shape  as  to  cause  the  compound  to  drag  while  removing,  they  should 
be  carefully  filled  with  wax  or  other  material.  If  the  second  or 
third  molar  inclines  forward  into  the  space  formerly  occupied  by  the 


60  EXAMINATION   OF  PATIENTS— RECORDS 

first  molar  to  such  an  extent  as  to  cause  overhanging  edges  and 
prevent  gettmg  a  good  impression,  the  difficulty  can  be  overcome 
either  by  placing  a  rounded  piece  of  soft  compound  longitudinally 
between  it  and  the  tooth  next  in  front,  and  allowing  it  to  harden  in 
such  a  shape  that  there  will  be  no  undercuts,  or  by  shaping  a  small 
piece  to  the  gum  and  mesial  surface  of  the  inclining  tooth,  to  which 
it  may  be  ligated  with  a  thread  when  necessary.  When  well  shaped 
and  sufficiently  hard,  it  can  be  covered  with  one  or  two  layers  of 
thin,  moist  paper  to  prevent  it  from  adhering,  and  the  rest  of  the  im- 
pression can  then  be  taken  in  plaster  of  Paris  or  modelling  com- 
pound. When  the  impression  is  removed,  the  parts  are  carefully 
placed  together  before  running  the  model. 

Cases  are  not  infrequently  presented  in  wliich  the  arch  is  con- 
tracted and  very  deep,  with  undercuts,  making  it  impracticable  to 
remove  the  impression  in  one  piece.  To  overcome  this,  a  small 
amount  of  the  compound  should  be  pressed  into  the  depression  and 
properly  shaped.  When  it  has  hardened,  the  surface  should  be 
rubbed  with  French  chalk,  or  covered  with  moist  tissue-paper,  and 
the  rest  of  the  impression  taken  as  usual.  After  the  removal  of  the 
parts,  they  should  be  carefully  i^laced  together  as  described.  When 
the  upper  teeth  are  protruding,  it  is  sometimes  advisable  to  make  the 
impression  in  two  parts. 

Not  infrequently  a  very  accurate  model  of  the  lingual  and  labial 
surfaces  of  the  teeth  is  needed,  as  in  making  regulating  and  retaining 
apparatus  in  cases  affected  with  pyorrhoea.  For  this  purpose  I  have 
devised  impression -trays,  having  one  shaped  for  use  in  the  front  and 
another  for  the  distal  part  of  the  arch.  They  are  made  of  rolled 
German  silver,  in  two  parts  or  lateral  halves,  for  covering  the  outer 
and  inner  sides  of  the  teeth  and  gum.  To  form  a  flange,  each  part 
or  side  of  the  tray  is  bent  nearly  to  a  right  angle.  These  lateral 
halves  are  joined  together  by  two  bars,  which  are  soldered  to  the 
flange  on  one  side  and  made  to  pass  through  short  cylinders  that  are 
soldered  to  the  flange  on  the  opposite  side,  and  so  arranged  that  as 
the  two  parts  are  pressed  together  in  taking  an  impression  the 
flanges  slide  by  one  another  over  the  grinding  surfaces  of  the  teeth. 
For  convenience  in  removing  the  tray,  a  small  hook  or  eyelet  is 
soldered  to  the  outer  side  of  each  half. 

The  impression  is  taken  by  first  placing  a  small  amount  of  softened 
compound  in  each  side  of  the  impression-tray  and  rubbing  the  sur- 


niPPvESSIONS  61 

face  thorouglily  with  soapstone.  The  tray  is  then  placed  over  the 
teeth  and  the  parts  pressed  gently  together  with  the  fingers  or  espe- 
cially devised  pliers.  It  is  essential  that  the  tray  be  held  steadily  in 
place  until  the  modelling  conipound  has  become  thoroughly  hard. 
The  parts  of  the  impression  are  then  separated  and  removed  with 
pliers  similar  to  those  used  for  adjusting  a  rubber-dam  clamp  by 
inserting  the  points  of  the  pliers  into  the  hooks  described.  The 
parts  are  readjusted  and  a  model  made  in  the  usual  manner. 

Water  injected  from  a  syringe  under  the  lip  at  the  median  line 
when  removing  an  impression  will  relieve  the  tendency  to  suction, 
and  thus  avoid  drawing  up  of  the  compound  in  the  centre,  which  so 
often  spoils  the  impression.  Forcing  Avater  under  the  lip  in  this 
manner  when  removing  plaster  impressions  is  an  invaluable  pro- 
cedure, as  it  furnishes  the  moisture  demanded  by  the  hardening 
plaster,  and  causes  it  to  separate  easily  from  the  mucous  membrane. 
If  an  accurate  impression  cannot  be  obtained  with  modelling  com- 
pound, it  should  be  taken  with  plaster  of  Paris. 

When  an  impression  is  made  of  a  model  with  modelling  compound, 
to  make  a  duplicate,  the  surface  of  the  model  and  the  warm  com- 
pound should  both  be  well  rubbed  with  French  chalk. 

I  had  occasion  to  take  an  impression  of  the  upper  and  lower  arch 
of  a  child,  two  years  and  ten  months  of  age,  for  the  purpose  of  cor- 
recting a  malposition  of  the  teeth  and  protrusion  of  the  lower  jaw. 
At  the  first  trial  it  was  found  impracticable  to  use  an  impression- 
cup,  and  a  piece  of  German  silver  wire.  No.  12  Brown  &  Sharpens 
standard  wire  gauge,  was  shaped  to  support  a  small  amount  of  com- 
pound for  its  introduction  into  the  mouth.  The  wire  was  formed 
into  a  short  loop  for  a  handle,  with  the  width  between  the  ends 
sufficient  to  pass  outside  of  the  arch  of  teeth.  I  gained  the  confi- 
dence of  the  child  by  first  biting  into  a  piece  of  the  soft  compound 
myself,  and  then  introducing  into  the  child's  mouth  a  small  amount 
of  the  compound  with  a  minute  piece  of  soft  candy,  saying  nothing 
to  her  about  the  candy.  After  the  second  trial,  the  mouth  was 
always  ready  and  waiting  for  the  impression-material.  A  sufficient 
amount  of  the  compound  was  then  prepared  on  the  wire  support 
with  a  little  candy  as  before,  and  quickly  placed  in  the  mouth,  and 
she  was  told  to  bite  her  teeth  into  the  compound.  She  willingly 
held  her  jaws  together,  the  tongue  pushing  the  soft  compound 
against  the  teeth  and  roof  of  the  mouth,  while  the  outer  part  was 


62  EXAMINATION  OF  PATIENTS— RECORDS 

pressed  against  the  teeth  and  gum  with  the  finger.  The  chin  was 
held  with  gentle  force,  and  the  compound  cooled  in  the  usual 
manner. 

Impression  of  the  Chin. — Impressions  of  the  chin  are  required  in 
the  construction  of  chin-caps  and  other  apparatus.  An  impression- 
tray  is  made  of  thin  sheet  gutta-percha,  or  by  bending  into  form  a 
piece  of  soft  material,  as  sheet  lead,  tin,  paste-board,  or  the  like. 
Sweet  oil  or  vaseline  is  applied  to  the  chin,  and  the  impression  is 
taken  with  plaster  of  Paris,  from  which  a  plaster  model  is  made. 

Preparing  and  carving  Models. — Before  plaster  of  Paris  is  run 
into  an  impression  for  making  a  model,  it  is  well  to  examine  the 
impression  and  correct  any  apparent  imperfections.  When  a  plate 
is  to  be  constructed  the  plaster  model  should  be  carefully  examined 
for  any  defects,  especially  at  the  necks  of  the  teeth.  The  plaster 
should  be  dressed  away  slightly  from  around  teeth  that  are  only 
partially  erupted,  to  allow  the  rubber  to  get  a  more  thorough  hold 
for  anchorage. 

The  carving  of  a  model  for  the  adjustment  of  a  spring-clasp 
attachment  for  anchorage  should  be  done  with  great  care. 

When  it  is  practicable,  examine  the  natural  teeth,  and  have  the 
plaster  form  an  exact  reproduction.  In  some  instances  the  anchor- 
age is  improved  by  over-carving  the  plaster  of  the  teeth  a  very  little 
at  their  necks.  When  the  teeth  are  short,  and  not  fully  erupted, 
the  gum  portion  at  their  necks  should  be  carved,  care  being  taken 
to  preserve  the  natural  form.  Carving  for  this  purpose  is  sometimes 
best  done  with  a  hoe-excavator,  not  dressing  too  much  of  the  plaster 
away,  but  cutting  a  groove  in  the  gum  portion  at  the  true  neck  of 
the  tooth.  A  partial-clasp  set  in  a  groove  in  this  manner  will  pre- 
vent the  solder  from  thickening  the  part  that  is  to  project  under  the 
free  margin  of  the  gum.     (See  Partial-Clasp,  }).  74.) 

Coloring  and  mounting-  of  Models. — From  the  beginning  of  my 
practice  I  have  preserved  records  of  cases  of  irregularities  in  the 
form  of  plaster  models,  colored  and  joined.  The  upper  and  lower 
mod(,*ls  are  united  with  a  hinge  made  of  brass  screw-eyes.  To 
the  end  of  tlie  screw  is  attached  a  small  piece  of  sheet  copper  or 
zinc  with  soft  solder  to  prevent  it  from  rotating  in  the  plaster.  The 
screw-eyes  have  a  section  of  the  circular  part  cut  out,  thus  making 
hooks  of  them.  The  hooks  are  placed  in  the  upper  half  of  the 
model,  and  screw-eyes  to  hinge  with  Ihcm  are  placed  in   tlie  lower 


Flu.  :v, 


Fig.  38. 


PROFILE   REOORDS  63 

part.  A  hole  drilled  in  tlio  plaster  by  the  side  of  the  screw-eye, 
and  a  piece  of  wood  inserted  in  position,  will  prevent  them  from 
unhinging. 

When  tlie  models  are  dry  they  are  smoothed  with  line  sand-paper 
and  soft  cloth,  after  which  they  are  usually  colored  witli  tube  oil 
paints.  The  pink  of  (he  gum  is  simulated  by  mixing  with  the  white 
a  little  rose  madder,  and  just  a  tinge  of  burnt  sienna  and  yellow, 
and  the  mixture  thinned  with  turpentine.  Tlie  borders  are  colored 
with  burnt  sienna.  When  the  paint  is  dry  a  coat  of  thin  white 
shellac  is  applied  to  give  a  hard  finish.  Too  much  paint  or  varnish 
should  be  avoided,  as  it  is  apt  to  turn  yellow  with  age.  The  models 
of  each  case  should  be  mounted  on  a  board,  arranged  in  the  order 
in  which  they  were  taken. 

In  place  of  coloring  the  models  with  paint,  after  being  dried  they 
are  sometimes  placed  in  melted  stearine  and  submitted  to  a  gentle 
heat.  The  stearine  strengthens  the  model  and  gives  the  surface  an 
ivory  appearance. 

Profile  Records. — A  simple,  accurate  metliod  of  making  a  record 
card*  for  recording  measurements  and  noting  the  extent  of  changes 
in  the  outline  of  the  features  is  made  by  taking  a  piece  of  soft  tin 
or  lead  wire,  round  or  square,  about  one-eighth  to  three-sixteenths 
of  an  inch  in  diameter,  and  shaping  it  carefully  with  the  fingers  to 
the  contour  of  the  features  at  the  median  line  from  the  forehead  to 
the  chin  (Fig.  37).  The  wire  should  not  be  permitted  to  press 
unequally  on  any  part.  After  the  wire  is  shaped,  it  is  well  sup- 
ported to  prevent  bending,  and  placed  on  strong  card-board,  several 
pins  being  stuck  into  the  card-board  close  in  front  of  it.  Trace  witli 
a  fine-pointed  pencil,  on  the  other  side  of  the  wire,  the  outlines 
formed ;  then  cut  the  card-board,  following  the  pencilled  line,  and, 
if  the  work  is  well  done,  the  card  will  fit  accurately  to  the  profile 
of  the  features  (Fig.  38). 

Any  other  angle  or  surface  measurement  can  be  obtained  in  the 
same  manner.  The  use  of  the  wire  and  card  is  of  advantage  in 
making  patterns  for  shaping  many  forms  of  external  regulating 
apparatus,  several  examples  of  which  will  be  mentioned. 

A  profilometer  (Fig.  39)  is  an  instrument  for  obtaining  facial 
outlines  for  record.     It  is  composed  of  sliding  rods  arranged  side  by 

*  Jacksun,  Transactions  of  the  New  York  Odontological  Society,  1895,  p.  75. 


64 


EXA^IINATION  OF  PATIENTS— RECORDS 


side  ill  a  frame  and  held  in  the  desired  position  with  a  clamp.  The 
ends  are  adjusted  to  the  contour  of  the  features,  and  pencil  mark- 
ings are  made  from  the  outline  secured. 

Another  instrument  for  measuring  facial  angles  is  a  facial  goni- 
ometer *  (Fig.  40).  Its  application  and  register  dial  will  be  under- 
stood from  the  engraving. 

Model  of  Face. — A  model  or  cast  of  the  face  in  plaster  of  Paris 
or  wax  is  an  excellent  means  of  recording  changes  in  facial  ex- 
pression brought  about  by  the  movement  of  the  teeth  and  process 
and  the  bony  framework  underlying  the  integument.  Dr.  A.  0. 
Hunt  has  described  his  method  of  making  plaster  casts  of  the  face, 
which  he  has  used  for  over  twenty  years.  Two  tubes,  about  two 
and  one-half  inches  long,   are  prepared    for  the  nostrils,  made  of 


Fig.  39. 


Fig.  40. 


Profilometer. 


Goniometer. 


No.  60  tin-foil,  usually  Avrapped  about  a  lead-pencil.  He  places  the 
patient  in  a  horizontal  position,  being  careful  that  lie  is  comfortable, 
so  that  it  will  not  be  necessary  to  change  his  position  until  the  opera- 
tion is  completed.  He  then  coats  the  skin,  where  he  wishes  the 
plaster  to  come  in  contact,  with  a  tliin  coating  of  the  best  olive  oil, 
being  careful  not  to  leave  any  surplus  of  it  in  the  wrinkles  of  the 
skin  or  about  the  fine  hairs,  as  an  excess  of  the  oil  will  not  permit 
of  a  well-defined  surface  of  the  cast.  Whenever  there  is  a  mous- 
tache or  beard,  or  when  he  desires  to  take  an  impression  well  up 
into  the  hair  above  the  forehead,  he  uses  a  lather  of  soap,  working 
it  carefully  into  the  hair.  The  tubes  of  tin-foil  are  then  slightly 
flattened  and  inserted  into  the  nostrils,  after  which  the  patient 
should  close  the  mouth  and  breathe  through  the  tubes  until  he  can 
do  so  with  ease  and  comfort.     A  bowl  of  plaster  is  then  mixed  to 


*  Gonioiiieler  as  recognized  by  Cuvier,  Sluiidard  Diclioiiary. 


Fig.  41. 


MODELLING  THE   FACE  65 

about  the  consistency  of  cream.  Another  bowl  is  to  be  made  ready 
at  the  right  time  by  an  assistant.  The  patient  is  cautioned  before 
the  {)iaster  lias  touched  tlie  face  to  hold  perfectly  still.  The  plaster 
is  first  applied  over  the  face  and  lips,  care  being  taken  to  have  it 
run  into  all  of  the  depressions,  and  then  gradually  over  the  parts 
that  liave  been  oiled,  air-bubbles  and  creases  being  carefully  avoided. 
The  cast  can  be  made  to  cover  the  neck,  chin,  and  side  of  the 
face.  If  the  ear  is  to  be  included,  the  deep  depression  should 
be  closed  witli  a  little  moist  paper  pulp,  and  something  placed 
underneath  tlie  ear  to  prevent  its  position  being  changed  by  the 
weight  of  the  plaster. 

My  method  of  making  plaster  casts  of  the  face  varies  only  in 
minute  detail  from  the  method  described.  In  making  the  mask  a 
sliield  is  first  placed  around  the  neck  and  head  to  form  the  outline 
and  prevent  the  plaster  from  flowing  beyond  the  desired  limit.  The 
shield  is  shaped  and  applied  as  seen  in  Fig.  41.  It  is  made  of 
strong  manilla  card-board  by  cutting  out  a  piece  similar  in  shape  to 
a  horseshoe,  the  part  passing  underneath  the  chin  being  about  two 
and  one-half  inches  wide,  and  gradually  narrowing  until  at  the  ends 
it  is  about  one  and  one-half  inches  w'ide.  The  inner  circle  of  the 
shield  sliould  be  so  shaped  that  when  the  ends  are  drawn  together 
the  outer  edge  will  flare  up  a  little,  so  as  to  more  thoroughly  retain 
the  plaster  which  flows  against  it.  The  upper  side  of  the  shield  is 
rubbed  with  vaseline  to  prevent  the  plaster  from  sticking  to  it. 
When  a  mask  of  only  one  side  of  the  face  is  to  be  made,  the  shield 
should  be  adjusted  to  pass  below  the  chin  and  ear  on  that  side,  and 
above  or  in  front  of  the  ear  on  the  opposite  side,  the  ends  being  tied 
together  at  the  back  of  the  head  with  tape. 

After  the  shield  lias  been  properly  adjusted,  the  patient  is  directed 
to  close  the  eyes  and  not  to  open  them  until,  told  to  do  so  after 
the  operation  is  completed.  If  these  directions  are  observed  no 
especial  discomfort  should  be  experienced.  The  face  is  thoroughly 
treated  with  a  thin  coat  of  olive  oil  or  warmed  vaseline,  care  being 
taken  to  supply  a  sufficient  amount  to  the  eyebrows  and  eyelashes. 
Apply  the  vaseline  with  a  soft  bristle  brush,  then  rub  the  surface 
thoroughly  with  the  hand,  which  results  in  giving  the  model  a  better 
skin  eftect.  A  wad  of  paper,  softened  in  water,  should  be  laid  under 
the  ear  to  support  it  and  to  prevent  the  plaster  from  running  under- 
neath ;  a  small  wad  is  placed  in  the  opening  of  the  ear  and  another 

5 


QQ  EXAMINATION   OF  PATIENTS— RECORDS 

in  the  deep  undercut.  Moist  modelling  clay,  worked  into  the  hair,  is 
used  when  there  is  a  moustache  or  beard.  In  ordinary  cases,  if  it  is 
desired  to  have  the  mask  extend  over  the  hair,  much  time  will  be 
saved  by  using  bibulous  or  tissue-paper  (either  dry  or  moist)  over 
the  hair,  around  the  ear,  and  on  the  forehead.  When  the  plaster 
is  sufficiently  hard  the  shield  should  be  removed  and  the  mask 
gently  raised.  In  some  instances  the  patient  can  assist  in  the  re- 
moval by  cautiously  working  the  muscles  of  the  face,  but  he  should 
never  separate  the  jaws.  The  impression  should  be  painted  over 
several  times  with  a  solution  of  green  soap,  or  immersed  in  or  painted 
with  a  solution  of  silicate  of  soda  and  water  before  pouring  the 
plaster  for  the  model.     Olive  oil  has  been  used. 

A  plaster-of-Paris  mask  of  the  complete  head  of  the  living  subject 
can  be  made  in  sections,  using  the  card  septum  for  dividing  in  the 
manner  shown  in  Fig.  38.  The  process  is  equally  applicable  to 
other  parts  of  the  body. 

Charts. — For  illustrating  methods  of  making  regulating  appli- 
ances, I  devised  a  series  of  charts,  which  are  particularly  useful  in 
describing  new  methods.* 

The  drawings  are  made  on  black  cambric  muslin,  which  is  pro- 
cured by  the  yard.  Along  one  edge  of  the  fabric  small  brass  rings 
are  sewed  about  six  inches  apart.  A  stout  cord  is  passed  through 
the  rings,  and  the  ends  are  tied  to  hooks  in  the  wall  in  any  con- 
venient position.  An  easel,  provided  with  a  board,  is  placed  back  of 
the  portion  of  the  muslin  to  be  painted.  Thumb-tacks  are  pressed 
through  the  cloth  into  the  board  to  hold  the  cloth  smooth  while 
painting  the  design.  Paint  is  applied  with  flat  bristle-brushes.  If  de- 
sired, an  outline  can  first  be  made  with  chalk.  Naturally  the  teeth  are 
painted  in  white.  The  metals  of  the  appliances  are  indicated  in  bright 
red.  This  strong  contrast  of  color  upon  the  dark  ground  is  readily 
seen  from  the  distant  part  of  an  ordinary  hall  or  class-room.  When 
the  drawing  is  finished  the  thumb-tacks  are  removed,  and  the 
muslin  is  drawn  along  the  cord  until  the  jjroper  space  is  obtained 
for  another  design.     The  drawings  can  be  numbered  by  painting 


*This  system  of  charts  is  especially  ajiplicahle  to  public  lectures,  class-room, 
and  laboratory  demonstrations  for  the  illustration  of  models,  appliances,  instru- 
ments, anatomical  and  physiological  specimens  or  drawings  of  any  nature  where 
the  eye  is  called  upon  to  assist  the  imaginalion. 


CHARTS  67 

the  figures  on  separate  pieces  of  cloth,  sewing  them  to  place,  and 
the  charts  rearranged  in  any  desired  order  by  simply  cutting  them 
apart  and  sewing  them  together  in  the  order  desired. 

When  a  duplicate  drawing  is  wanted,  a  blank  piece  of  muslin  is 
placed  smoothly  across  a  freshly  painted  drawing,  and  the  fold  is 
pressed  lightly  with  a  large  roll  of  cloth  or  other  material.  If  care  is 
exercised,  three  such  reproductions  can  be  made.  Parts  imperfectly 
copied  should  be  touched  up  with  fresh  paint.  The  paint  becomes 
dry  in  about  three  days,  when  the  charts  may  be  bundled  together, 
so  that  a  number  of  them  can  be  strung  on  a  comparatively  short 
cord,  but  they  should  not  be  rolled  in  less  than  a  week  after  painting. 


CHAPTER  V 
AGE  FOR  REGULATION 

Each  irregular  tooth  should  be  aided  to  take  a  correct  position  in 
the  circle  of  the  arch  while  erupting,  or  as  soon  thereafter  as  practi- 
cable, not  only  in  order  to  promote  the  proper  development  of  the 
jaws,  but  because  the  teeth  next  to  be  erupted  will  be  more  likely 
to  do  so  in  proper  position  and  order.  Only  a  portion  of  the  alveolar 
process  that  forms  the  sockets  for  the  roots  of  the  teeth  is  developed 
until  the  teeth  are  fully  erupted.  For  this  reason  a  slight  pressure 
is  sufficient  to  change  their  position.  When  the  force  is  properly 
applied  there  is  no  danger  of  strangulation  of  the  pulps  of  the 
teeth,  and  no  pain  or  especial  discomfort  should  be  experienced. 
But  if  too  much  pressure  is  put  on  prominent  teeth  when  adjoin- 
ing ones  are  erupting,  it  is  likely  to  wedge  the  erupting  teeth  to 
such  an  extent  as  to  arrest  their  development. 

There  is  a  natural  contraction  of  the  alveolar  process  as  one 
approaches  maturity,  and  any  tendency  to  irregularity,  if  not  cor- 
rected, causes  the  irregularity  to  become  confirmed,  as  the  alveolar 
process  at  this  time  is  taking  on  its  normal  density. 

When  the  child  has  inherited  the  small  jaw  of  one  parent  and 
the  large  teeth  of  the  other,  the  conditions  should  be  harmonized  by 
the  early  and  gradual  expansion  of  the  arch,  thus  encouraging  the 
development  of  the  bone  and  process.  The  suture  of  the  premaxil- 
lary  and  of  the  maxillary  bone  is  not  fully  united  in  early  childhood, 
and  at  this  time  there  is  a  greater  disposition  for  the  tissues  to 
adapt  themselves,  the  bone,  and  especially  the  alveolar  process, 
being  developed  to  follow  the  position  of  the  teeth.  At  a  later  stage, 
when  the  tissues  have  become  hardened  with  bony  dejjosit,  these 
changes  are  not  so  readily  brought  about,  and  the  result  of  expan- 
sion or  the  movement  of  the  teeth  is  generally  less  satisfactory. 

Ccmtinuous  pressure  on  any  living  animal  tissue  causes  absorp- 
tion ;  but  the  alveolar  process  contains  more  organic  substance  than 
tooth-structure,  and,  when  force  is  applied  to  it,  the  process  yields 
and  allows  the  tooth  to  be  moved  without  a  corresponding  absorp- 
tion of  the  root. 
68 


AGE  FOR  REGULATION  69 

The  deciduous  teeth  usually  erupt  in  jrood  position,  and  their 
re.ffulation  is  seldom  required,  except  for  the  lateral  expansion  of  the 
arch.     Occasionally,  however,  the  incisors  and  cuspids  are  rnalposed. 

The  age  at  which  to  regulate  should  be  determined  by  the  health 
and  temperament  of  the  patient,  and  by  the  question  as  to  whether 
the  irregularity  is  inherited.  Delay  on  the  part  of  the  parent  or 
guardian  may  also  prove  a  factor.  I  was  once  consulted  regarding 
the  case  of  a  child  aged  two  years  and  ten  months  (Figs.  184—186), 
in  which  the  deciduous  incisors  and  cuspids  of  the  lower  arch  had 
closed  in  front  of  the  upper,  occluding  with  the  gum,  causing  the 
lower  jaw  to  be  extremely  prognathous.  If  these  conditions  had 
been  allowed  to  continue,  even  until  the  time  of  the  eruption  of  the 
permanent  teeth,  the  occlusion  and  the  shape  of  the  jaws  would 
have  become  so  considerably  changed  that  there  would  have  been 
an  obstinate  case  of  irregularity  to  contend  with.  Early  regulating 
is  frequently  essential  in  cases  where  the  deciduous  molars  liave 
been  extracted  prematurely.  The  loss  of  the  molars  removes  the 
natural  support  from  the  sides  of  the  arch,  and  the  anterior  circle  is 
not  expanded  and  pushed  forward,  as  it  naturally  should  be,  by  the 
wedging  of  the  permanent  incisors ;  but  in  the  process  of  eruption, 
the  permanent  incisors,  which  are  broader  than  the  deciduous  ones, 
force  the  cuspids  to  take  a  position  in  the  spaces  caused  by  the 
extraction.  Also,  as  a  result  of  the  extraction,  the  first  permanent 
molars  gradually  move  forward,  usurping  much  or  all  of  the  remain- 
ing space  intended  for  the  bicuspids.  An  example  of  this  condition 
will  be  seen  in  Fig.  159. 

There  are,  however,  early  irregularities  of  the  permanent  teeth  in 
the  lower  and  upper  arch  that  will  gradually  assume  a  good  position 
when  left  to  nature.  Such  are  instanding  laterals  and  slight  torsion 
of  the  upper  central  incisors  ;  each  of  these,  in  the  majority  of  cases, 
will  gradually  take  a  correct  position  through  the  influence  of  oc- 
clusion and  the  pressure  of  the  tongue  and  lips  in  connection  with 
the  progressive  development  of  the  jaw  and  process.  Bearing  this 
fact  in  view,  the  operator  should  carefully  consider  the  probabilities 
of  the  case. 

•  When  the  irregularity  is  inherited,  the  teeth  will  generally  need  to 
be  retained  after  regulating  much  longer  than  otherwise,  and  in 
some  cases  it  may  be  an  advantage  to  delay  the  regulation  until 
after  the  eruption  of  the  second  molars. 


70  AGE   FOR   REGULATION 

All  objection  made  against  the  early  correction  of  the  position  of 
the  incisors,  as  from  torsion,  is  that  the  retaining  fixture  might  need 
to  be  worn  for  a  considerable  length  of  time  to  prevent  the  teeth 
returning  to  their  original  position,  and  this  at  an  age  when  the  child 
would  not  be  likely  to  be  attentive  in  the  care  of  the  teeth  and  ap- 
pliance. The  continued  retention  of  the  teeth  in  such  a  case  is 
necessary,  as  the  lateral  pressure  of  the  incisors  is  not  usually  les- 
sened until  long  after  the  permanent  cuspids  have  become  fully 
erupted. 

To  correct  the  position  of  prominent  incisors  when  there  is  insuf- 
ficient room  in  the  anterior  arch,  it  is  sometimes  necessary  to  extract 
the  first  bicuspids.  When  the  protrusion  is  extreme,  and  is  known 
to  be  inherited,  the  regulating  should  be  begun  early,  even  by  re- 
moving the  deciduous  first  molars  and  the  developed  portions  of 
the  first  bicuspids,  sacrificing  some  of  the  process  if  need  be,  and 
immediately  applying  pressure  to  force  the  incisors  backward  to  a 
proper  position,  closing  the  spaces.  This  early  procedure,  before 
the  full  eruption  of  the  bicuspids,  is  necessary  only  in  cases  where 
the  upper  incisors  are  resting  on  or  in  front  of  the  lower  lip,  as  this 
influence  alone,  when  continued,  will  cause  the  teeth  to  become 
more  prominent. 

In  determining  whether  to  correct  the  position  of  the  teeth  for 
mature  patients,  the  age  is  not  so  much  to  be  taken  into  considera- 
tion as  is  the  permanent  advantages  to  be  gained  by  an  operation, — 
namely,  the  improved  occlusion  and  appearance  of  the  teeth,  the 
prevention  of  excessive  wear  on  them,  and  the  contour  of  the 
features.  In  the  case  of  older  patients,  the  health  and  firmness  of 
the  teeth  in  their  sockets  must  naturally  be  considered,  and  whether 
they  are  affected  with  calcareous  deposits  or  pyorrhoea  alveolaris.  I 
have  been  successful  in  the  correction  of  many  cases  of  irregularity 
in  patients  from  forty  to  fifty  years  of  age. 


CHAPTER  VI 
EXTRACTION  OF  TEETH  FOR   RELIEVING  IRREGULARITIES 

The  extraction  of  a  deciduous  lateral  incisor  to  cause  additional 
room  for  an  erupting  permanent  incisor  is  sometimes  improperly- 
resorted  to,  and  also  the  extraction  of  a  deciduous  cuspid  to  increase 
the  space  for  an  erupting  lateral  incisor.  This  procedure  is  objec- 
tionable. The  adjoining  deciduous  teeth  should  be  preserved,  and 
the  permanent  teeth  left  to  wedge  their  way  into  place  and  not 
allowed  to  encroach  upon  the  space  that  should  be  preserved  for 
the  adjoining  erupting  permanent  teeth. 

When  the  teeth  are  crowded  in  the  arch,  and  their  regulation  has 
been  put  off  until  all  of  the  permanent  ones  have  been  erupted,  the 
expansion  of  the  arch  to  make  room  for  the  irregular  teeth  is  not 
always  effectual  (Fig.  84) ;  the  extraction  of  a  tooth  on  one  or  both 
sides  of  the  arch  will  sometimes  give  a  more  desirable  result. 

I  deprecate  the  loss  of  any  of  the  permanent  teeth,  and  avoid  their 
extraction  whenever  possible,  but  in  some  cases  a  better  result  is 
attained  by  extraction,  especially  where  the  child  has  inherited 
larger  teeth  than  the  jaw  will  accommodate.  The  articulation  and 
contour  of  the  arch  can  sometimes  be  improved  materially  by  early 
and  judicious  extraction.  On  the  other  hand,  where  it  can  be 
determined  from  the  family  history  and  from  examination  that  the 
features  are  to  be  large,  with  prominent  nose  and  cheek-bones,  the 
early  extraction  of  the  permanent  teeth  should  be  avoided,  even 
though  the  teeth  are  considerably  crowded,  as  later  it  may  be  found 
that  the  development  of  the  jaws  will  leave  undesirable  spaces 
between  the  teeth,  and  the  result  will  be  a  sunken  appearance  at  the 
location  of  the  canine  ridge,  which  is  always  undesirable. 

In  another  chapter  are  described  methods  of  expanding  the  narrow, 
contracted  arch,  either  before  or  after  the  loss  of  the  deciduous 
teeth,  for  the  purpose  of  encouraging  the  permanent  ones  to  take  a 
normal  position  while  erupting.  If  this  has  been  neglected,  and  the 
teeth  in  the  front  of  the  arch  have  been  allowed  to  assume  irregular 
positions,  they  usually  settle  together  and  occupy  less  space  in  the 
circle  than  when  in  a  normal  line.     This  permits  the  teeth  on  the 

71 


fj. 


EXTRACTION   FOR   RELIP:VING   IRRECtULARITIES 


sides  of  the  arch  to  follow  their  natural  inclination  and  move  forward 
towards  the  front  of  the  arch,  and  likewise,  when  the  deciduous 
molars  are  lost  earlier  than  should  be,  the  permanent  teeth  on  the 
sides  of  the  arch  gradually  move  forward.  At  this  stage  expansion 
would  not  relieve  the  difficulty.  If  either  of  these  latter  conditions 
exist  it  is  necessary  to  move  the  teeth  on  the  sides  of  the  arch  back- 
ward again,  or  to  extract  one  or  more  of  them  to  provide  the 
rec|uired  sjjace  for  the  correction  of  the  irregular  ones.  Otherwise, 
tlie  placing  of  the  teeth  of  the  front  of  the  arch  in  position  would 
enlarge  the  anterior  circle  and  cause  them  to  become  too  prominent. 

In'cisors. — The  incisors  give  symmetry  and  beauty  to  the  expres- 
sion of  the  mouth,  and  their  extraction  should  always  be  avoided,  at 
least,  until  it  is  found  by  the  most  careful  consideration  that  their 
removal  is  required.  There  are  but  few  conditions  presented  to  the 
practitioner  wherein  the  extraction  of  a  permanent  incisor  for  the 
purpose  of  regulating  is  justifiable.  In  my  practice  I  have  not  been 
obliged  to  resort  to  this  extreme  measure  in  the  upper  arch. 

Occasionally  a  case  is  presented  with  an  harmonious  articulation 
of  the  teeth,  except  that  the  lower  incisors  overlap  one  another, 
with  the  distance  between  the  cuspids  too  narrow  for  their  proper 
accommodation.  To  broaden  the  space  by  moving  the  cuspids  out- 
ward would  interfere  with  the  occlusion,  and  might  require  the  teeth 
of  the  upper  arch  to  be  moved  outward  also.  These  conditions 
sometimes  justify  the  extraction  of  the  lower  incisor  that  most  aids 
their  correction.  By  way  of  example.  Fig.  202  illustrates  a  case  in 
which  a  fairly  satisfactory  result  was  attained  by  extracting  one  of 
the  lower  incisors  (one  of  the  lower  incisors  having  been  extracted 
several  years  previous)  and  moving  the  two  others  forward.  This 
procedure  filled  the  space  between  the  cuspids,  and  as  these  were 
in  good  jKJsition  and  of  good  structure,  the  removal  of  the  incisor 
was  considered  the  bettor  practice.  The  cuspids  were  then  dre.ssed 
with  a  coruiiduiu  slouo  so  as  to  more  nearly  conform  to  the  shape 
of  the  incisors. 

When  an  incisor  is  decayed  or  fractured  so  that  it  cannot  be  util- 
ized, it  can  be  extracted  and  the  adjoining  teeth  dr^wn  together 
laterally  to  riose  the  space,  providing  the  contraction  of  the  arch  in 
this  manner  docs  not  interfere  with  the  occlusion.  This,  in  some 
inshmccs,  is  better  ihan  to  supjjly  an  artificial  to(jlh. 

it  is  sometimes  more  satisfactory  to  remove  a  lateral  incisor  that 


INCISORS,  CUSPIDS,  BICUSPIDS 


73 


Fiu.  42. 


has  erupttMl  far  inside  of  tiie  circle  of  the  arch,  the  cuspid  having 
taken  a  position  in  front  of  it,  than  to  extract  a  l)icuspid  or  cuspid  to 
make  room  for  it  (Fig.  42). 

Cuspids. — The  cuspids  are  among  ttie  strongest  of  tlie  teeth. 
Owing  to  their  character  and  shape,  and  to  the  prominence  of  tlieir 
roots,  tlieir  loss  is  generally  detrimental  to  the  contour  of  the  fea- 
tures. The  removal  of  a  cuspid  results  in  the  absorption  of  the 
canine  ridge,  wliicli  should  be  preserved,  as  it  gives  character  to  the 
face  and  determines  the  outline  of  the  wing  of  the  nose  and  upper 
lip.  When  the  cuspids  are  considerably  prominent,  or  when  their 
crowns  are  growing  forward,  the  laterals  and  bicuspids  being  of  good 
structure  and  in  good  position,  the  removal  of  a  prominent  cuspid 
often  saves  the  necessity  of  regulating,  and  if  the  position  and  shape 
of  the  bicuspid  is  similar  to  the 
cuspid  the  loss  is  not  usually 
noticeable,  and  therefore  not 
especially  objectionable. 

Fig.  200  illustrates  the  posi- 
tion of  the  teeth  in  the  upper 
arch  of  Miss  H.  The  buccal 
contour  of  the  bicuspids  is  simi- 
lar to  the  shape  and  contour 
of  the  cuspids.  There  was  no 
space  in  the  circle  for  the  normal 
eruption  of  the  cuspids,  and 
they  had  taken  a  position  in 
front    of   the    lateral    incisors. 

The  cuspids  were  extracted,  and  the  laterals  moved  outward,  which 
gave  a  good  result,  as  shown  in  Fig.  201. 

Bicuspms. — The  bicuspids  are  the  teeth  usually  chosen  to  be  ex- 
tracted to  gain  space  for  the  correction  of  the  })osition  of  prominent 
incisors  and  cuspids,  generally  removing  tlie  first  bicuspid  on  each 
side  of  the  arch.  If  the  second  bicuspid  is  smaller  and  has  poor 
occlusion,  which  is  often  the  case,  or  if  it  is  not  as  perfect  a  tooth 
as  the  first,  it  is  preferable  sometimes  to  remove  the  second  bicuspid 
rather  than  the  first.  However,  it  is  generally  a  mistake  to  remove 
the  second  bicuspids,  as  they,  with  tlie  molars,  form  the  anchorage 
for  moving  inward  tlie  six  front  teeth  ;  and  their  extraction  lessens 
the  anchorage  by  one  tooth  on  each  side,  and  also  adds  one  to  the 


74  EXTRACTION   FOR  RELIEVING  IRREGULARITIES 

number  to  be  moved  backward.  (See  description  accompanying 
Fig.  467.)  Again,  in  case  the  second  bicuspid  is  extracted,  the 
backward  movement  of  the  cuspid  and  first  bicuspid  sometimes 
causes  the  latter  to  pitch  backward  so  as  to  take  an  unsightly- 
angle. 

When  it  is  decided  to  extract  a  bicuspid  in  the  upper  arch  the 
prominence  of  the  lower  arch  should  be  examined  also,  and  if  the 
teeth  are  crowded  the  corresponding  bicuspid  should  be  extracted ; 
otherwise,  the  inward  pressure  of  the  front  teeth  of  the  upper  arch 
against  those  of  the  lower  will  generally  cause  them  to  crimp  and 
become  irregular. 

Not  infrequently,  early  in  life,  one  jaw  develops  more  rapidly  than 
the  other.  When  this  is  due  to  heredity  the  anterior  growth  of  the 
jaw  can  sometimes  be  lessened  by  the  extraction  of  the  first  decidu- 
ous molars  and  the  undeveloped  first  bicuspids,  care  being  taken 
not  to  interfere  with  the  bony  sockets  surrounding  the  adjoining 
erupted  or  non-erupted  teeth. 

When  the  second  deciduous  molar  is  removed  before  the  eruption 
of  the  first  permanent  molar,  the  latter  moves  forward,  and  when 
erupted  it  is  almost  sure  to  occupy  the  position  belonging  to  the  sec- 
ond bicuspid,  so  that  when  the  bicuspid  appears  there  is  insufficient 
space  for  it,  and  it  erupts  either  inside  or  outside  of  the  normal  line. 
If  the  bicuspid  is  driven  far  out  of  position,  it  is  sometimes  found 
more  advisable  to  remove  it  than  to  force  the  molar  backward  to 
give  it  room.  ^ 

Molars. — The  first  permanent  molar  is  physiologically  and  me- 
chanically the  most  important  tooth  for  mastication  in  the  arch.  Its 
large  crown-surface,  situated  where  the  strain  of  mastication  is  the 
greatest  from  first  to  last,  admirably  adapts  it  to  bear  the  stress ;  but 
its  early  development,  before  six  years  of  age,  when  there  is  insuffi- 
cient nutrition  owing  to  the  groat  demand  of  other  parts  of  the  bony 
frame,  causes  it  to  be  of  weak  structure  and  very  liable  to  decay. 
In  cases  of  irregularity  these  teeth  are  often  found  so  broken  down 
that  it  seenjs  imperative  that  they  should  be  the  ones  to  be  removed. 
When  either  the  upper  or  lower  arch  is  too  prominent,  and  extrac- 
tion is  required,  it  is  advisable  to  examine  the  jaw  carefully  before 
determining  which  tooth  shall  be  removed,  to  see  if  there  is  likely  to 
be  sufficient  room  for  the  eruption  of  the  wisdom-tooth.  If  not,  it 
may  be  concluded  that  the  jaw  will  become  still  more  prominent 


MOLARS  75 

through  the  natural  anterior  development,  and  the  sixth-year  molars, 
if  defective,  may  be  removed. 

Many  practitioners  still  advise  the  extraction  of  the  first  permanent 
molars  for  relieving  the  crowded  condition  of  the  teeth,  but  the 
detrimental  effects  that  arise  from  their  early  removal  should  prompt 
us  to  study  means  for  their  preservation. 

A  recent  writer  advises  the  extraction  of  the  first  permanent 
molars  at  about  six  months  before  the  eruption  of  the  twelfth-year 
molars.  But  the  deciduous  molars  being  lost  a  little  before  this  time, 
and  the  bicuspids  not  being  erupted  sufficiently  to  articulate,  the  child 
would  be  left  in  a  sad  plight  as  regards  mastication  for  a  consider- 
able length  of  time,  until  the  second  permanent  molars  were  erupted, 
and  then  there  would  be  only  one  molar  tooth  on  each  side  of  the 
jaw,  which  might  not  occlude  well  for  mastication  until  the  third 
molars  were  erupted.  Again,  the  extraction  of  the  first  permanent 
molars  in  the  lower  arch,  especially  before  the  full  form  of  the  jaw 
has  been  attained,  not  uncommonly  results  in  arresting  its  anterior 
development,  causing  recession  of  the  lower  jaw,  with  the  lower 
incisors  closing  far  back  of  the  upper  ones.  The  early  extrac- 
tion of  the  first  molars  is  advisable  in  some  forms  of  prognathous 
jaw. 

The  simple  extraction  of  a  molar  or  bicuspid,  without  mechanical 
interference,  does  not  usually  lessen  the  crowded  condition  of  the 
teeth  in  the  front  part  of  the  arch. 

In  cases  where  the  lower  arch  is  prominent,  the  teeth  being 
crowded  and  the  angle  of  the  jaw  obtuse,  it  is  sometimes  an  advan- 
tage to  remove  the  second  or  the  third  molar. 


CHAPTER    VII 

ANCHORAGE  AND  APPLIANCES 

The  first  essential  of  a  regulating  appliance  is  that  it  shall  be  well 
anchored,  having  fixed  points  of  resistance  from  which  force  can  be 
exerted  for  the  correction  of  irregular  teeth. 

Anchorage  is  usually  gained  by  attaching  apparatus  to  the  crowns 
of  the  bicuspids  and  molars,  although  when  desirable  other  teeth 
are  utilized. 

When  the  teeth  employed  for  anchorage  are  in  an  irregular  posi- 
tion their  correction  should  not  be  undertaken,  nor  should  they  be 
disturbed  in  their  sockets  until  the  positions  of  all  other  irregular 
teeth  are  corrected,  as  teeth  which  have  once  been  moved  are  not 
as  firm  as  before,  and  are  more  liable  to  be  changed  in  their  position 
by  force  applied  to  them  as  anchorage  teeth. 

Jackson  System  of  Anchorage. — Attention  is  called  to  the  method 
devised  by  me  for  anchoring  appliances  to  the  teeth  with  spring-clasp 
attachments.  These  are  fitted  to  one  or  more  of  the  molars  or  bicus- 
pids on  each  side  of  the  arch,  in  some  cases  depending  entirely  on 
them  for  anchorage  ;  in  other  cases,  using  in  conjunction  with  them 
partial-clasps  on  adjoining  teeth.  The  appliance  is  made  in  such  a 
manner  that  it  can  be  removed  and  replaced  when  desired  for 
cleansing  or  putting  on  more  pressure. 

Spring-Clasp  Attachment. — This  term  is  applied  to  the  part  of 
the  device  that  clasps  a  tooth  for  anchorage.  It  is  made  usually  of 
plate-metal  and  spring-wire  united  with  solder. 

The  parts  of  the  spring-clasp  attaclmient  are  named  pai-tial-cla-sp 
and  spring-clasp.     They  are  made  as  follows  : 

Partial- Clasp. — A  partial-clasp  is  a  thin  piece  of  plate-metal 
shaped  to  fit  tlio  side  of  a  tooth,  in  thickness  about  No.  35  U.  S. 
standard  wire  gauge  (Brown  6c  Sharpe).  It  is  made  of  gold,  gold-faced 
platinum,  platinoid,  German  silver,  or  any  suitable  metal.  Platinoid 
and  German  silver  have  been  used  extensively  for  this  purpose,  and 
have  their  advantages  when  soil  solder  is  used,  but  preference  is 
generally  given  to  the  precious  metals,  as  they  are  less  liable  to 
oxidize. 
7fi 


SPRING-CLASP   ATTACHMENT 


77 


A  correct  plaster  model  of  the  teeth  is  first  prepared,  and  a  piece 
of  tlie  plate-metal  is  hollowed  to  fit  accurately  one  side  of  each  of 
the  teeth  that  are  to  be  used  for  anchorage.  It  can  be  placed  either 
on  the  lingual  or  buccal  side,  this  being  determined  by  the  style  of 
appliance  to  be  adopted,  but  the  partial-clasp  is  always  arranged  on 
the  side  of  the  tooth  on  which  the  base-wire  or  foundation  of  the 
appliance  is  to  be  attached.  (The  base-wire  is  described  later  in 
this  chapter.) 

When  the  shape  of  the  tooth  is  unsuited  for  anchorage,  and  in 
some  particular  forms  of  apparatus,  it  is  an  advantage  to  have  a 
partial-clasp  on  both  the  labial  and  lingual  sides,  but  the  partial- 
clasp  to  which  the  base-wire  is  to  be  attached  is  always  to  be  made 
broad,  to  extend  from  the  neck  to  the  grinding  surface,  and  the  one 
on  the  opposite  side  of  the  tooth  is  usually  made  narrow  and  fitted 
accurately  at  the  neck. 

The  partial-clasp  is  formed  by  hollowing  or  contouring  a  strip  of 
metal  of  the  desired  width  and  length  with  contouring  pliers.  The 
pliers  should  liave  the  side  of  one  beak  shaped  into  a  small  concave 
depression  into  which  fits  a  contoured  prominence  on  the  corre- 
sponding beak,  like  the  S.  S.  White  contouring  pliers  (Fig.  43). 

There  are  many  varieties  of  pliers  on  the 
market,  but  1  have  found  only  this  one  with 
the  concave  depression  and  contoured  promi- 
nence sufficiently  small  to  be  suitable  for 
this  work.  The  metal  is  placed  between  the 
beaks  of  the  pliers  and  pressed  repeatedly 
until  it  is  evenly  contoured.  It  is  prefer- 
able that  the  metal  be  over-  rather  than 
under-contoured  before  it  is  applied  to  the 
tooth,  which  will  allow  for  any  inaccuracies 
that  may  have  occurred  from  injury  to  the 
surface  of  the  model.  As  the  metal  is 
being  contoured,  it  should  be  dressed  with 
scissors  to  tlie  required  form,  shaped  to 
press  well  up  about  the  neck  of  the  tooth, 
and    at    the    same   time    curved   sufficiently 

over  the  prominences  towards  tlie  grinding  surface  to  prevent  the 
appliance  when  finished  from  })ressing  on  the  gum  (Fig.  44). 

Another  method  of  contouring  the  metal  is  by  placing  it  upon  a 


yui.  43. 


78 


ANCHORAGE   AND   APPLIANCES 


Fig.  44. 


Fig.  45. 


flat  piece  of  lead  and  stamping  it  repeatedly  with  a  small  round- 
headed  die  until  the  desired  form  is  obtained. 

In  iitting  the  partial-clasp  to  the  plaster  model   it  should  not  be 
burnished,  but  pressed  into  place  usually  with  the  finger,  using  the 
thumb-nail  to  bend  the  edges  of  the  metal  into  the  de- 
pressions of  the  tooth. 

When  the  crown  of  the  tooth  to  be  clasped  is  short,  not 
fully  erupted,  or  of  poor  form  for  anchorage,  the  model 
should  be  carved  more  at  the  neck,  not  disturbing  the 
natural  shape  of  the  tooth,  and  the  partial-clasp  made 
wide  enough  to  extend  up  to  the  true  neck  of  the  tooth 
and  over  the  prominences  towards  the  grinding  surface, 
with  the  ends  shaped  to  extend  around  the  approximal  surfaces  as 
far  as  is  practicable,  especially  near  the  neck,  to  assist  in  retaining. 
The  antero-posterior  width  of  the  tooth 
is  less  at  this  point  than  towards  the 
grinding  surface,  and  shaping  the  metal 
to  this  part  will  assist  the  anchorage  of 
the  appliance.  If  the  gum  is  quite  promi- 
nent and  firm,  it  is  occasionally  advisable 
to  make  the  partial-clasp  of  thicker  metal, 
so  that  it  will  be  sufficiently  strong  to 
project  under  the  free  margin  of  the 
gum  without  the  usual  addition  of  solder 
on  that  part.  This  will  clasp  the  tooth 
equally  well,  and  be  less  liable  to  irritate 
the  gum. 

It  is  usually  desirable  to  have  adjoining 
teeth  assist  in  the  anchorage.  Partial- 
clasps  are  fitted  to  each,  and  made  to 
meet  at  their  junction. 

A  continuous  partial-clasp  is  made  of 
one  piece  of  metal  resting  on  several 
teeth,  either  contoured  with  pliers  or 
swaged  to  fit  their  surface. 

Sp7'inf/-Clasp. — The  spring-clasp  is  formed  with  a  clasp-bender 
similar  to  the  one  illustrated  in  Fig.  45.  The  clasp-bender  should 
be  of  small  size.  Most  of  those  on  the  market  are  rather  large  for 
the  purposes  required,  as  they  do  not  make  sufficiently  short  curves. 


PARTIAL-CLASP— SPRING-CLASP 


79 


The  round  beak  should  be  of  about  the  same  width  near  the  joint  as 

it  is  at  the  outer  end. 

The  spring-clasp  is  made  of  a  spring-wire  of  any  suitable  metal, 
usually  of  spring-gold,  German  silver,  or  platinoid  (piano-wire  has 
been  employed),  in  size  about  No.  21  gauge,  or  a  little  larger,  as  the 
case  may  require.  It  is  shaped  to  fit  near  the  gum  on  the  buccal  or 
opposite  side  of  the  tooth  from  the  partial-clasp  described.  Both 
ends  pass  over  the  arch,  resting  in  the  depressions  at  the  junction 
with  the  adjoining  teeth,  and  are  curved  about  the  lingual  side  near 
the  gum  line  to  rest  on  the  partial-clasp ;  but  the  spring  should  fit 
loosely,  so  that  it  will  not  injure  the  plaster  model  in  removing  it 
(Fig.  46).     The  wire  is  most  easily  formed  by  first  bending  it  twice 


Fig.  47. 

Fig.  46. 

d 

t^ i 

^  m  1 

Fig.  48. 


Fig.  49. 


at  right  angles  with  the  clasp-bender  (bending  it  slowly  to  prevent 
breaking),  having  the  width  between  the  parallel  sides  of  the  wire 
equal  to  the  antero-posterior  width  of  the  tooth  to  be  clasped 
(Fig.  47).  The  part  that  is  to  clasp  the  neck  of  the  tooth  is  then  so 
curved  with  the  clasp-bender  that  it  will  be  perfectly  adapted  to  the 
curve  of  the  buccal  side.  This  part  of  the  shaping  should  always 
be  done  before  bending  the  parallel  wires  downward.  It  is  advisable 
to  mark  the  wire  where  it  is  to  be  bent.  Both  of  the  wires  are  then 
marked  and  placed  in  the  clasp-bender  (or  each  one  separately)  at  a 
proper  distance  from  the  curved  portion,  and  bent  nearly  at  a  right 
angle  to  cause  them  to  pass  over  the  grinding  surface  at  the  junction 
with  the  adjoining  teeth  (Fig.  48),  and  again  bent  in  a  similar  manner 
to  extend  towards  the  neck  of  the  tooth,  with  the  ends  bent  towards 
each  other  at  the  gum  line,  so  that  they  will  rest  on  the  partial-clasp 
previously  described  (Fig.  49). 

The  principle  of  the  clasping  power  of  this  attachment  to  the 


80 


ANCHORAGE   AND   APPLIANCES 


Fig.  .'0. 


sides  and  neck  of  the  tooth  is  shown  in  Fig.  50.  The  contoured 
partial-clasp  is  located  on  one  side,  covering  the  prominences  of  that 
side  of  the  tooth,  with  the  ends  at  the  gum  line  extending  slightly 
around  the  tooth  to  grasp  it  antero-posteriorly.  The  spring-clasp 
extends  from  the  partial-clasp  in  a  semicircular  form  up 
over  the  grinding  surface,  at  the  junction  with  the  adjoin- 
ing teeth,  and  down  on  the  opposite  side  to  the  gum  line, 
where  the  wire  crosses  and  rests  on  the  full  width  of  the 
tooth.  The  ends,  when  finally  soldered  to  the  partial- 
clasp,  complete  the  spring-clasp  attachment,  wliich,  hi 
effect,  grasps  the  tooth  as  does  a  rubber-dam  clamp. 
The  grasping  power  of  this  attachment  depends  much 
upon  the  elastic  properties  and  strength  of  the  metal  used  for  the 
spring. 

The  spring-clasp  passes  over  the  arch  at  the  junction  of  the  teeth ; 
the  models  of  the  upper  and  lower  arch  should  necessarily  be 
examined  together,  that  the  wire  may  be  well  located. 

Base-Wire. — A  base-wire  is  a  curved  metal  bar  forming  the 
foundation  of  a  regulating  appliance. 

The  base-wire  can  be  made  of  round,  square,  or  flat  metal,  or  by 
a  combination  of  these  forms.  Round  wire  is  usually  preferred,  as 
it  can  be  reshaped  by  bending  in  any  direction  ;  while  with  the  wire 
in  any  other  form  it  is  difficult  to  attain  the  same  results. 

The  metals  generally 
employed  are  spring- 
gold,  platino- iridium, 
platinoid,  or  German 
silver. 

In  making  an  ap- 
pliance for  either  the 
upper  or  lower  arcli, 
the  base-wire  may  be 
shajjed  in  any  form  best 
suited  for  a  foundation. 
To  a.ssist  in  design- 
ing an  apparatus,  it  is 
advi.sable  to  use  tin  or 
lead  wire,  whirh  is  very  pliable,  sha|)ing  it  to  the  model,  following 
the  lines  which  it  is  intended  that  the  metals  of  the  appliance  shall 


Fig.  51. 


BASE-WIRE 


81 


0(cui)y.  Ill  Uiis  manner  llio  appearance  and  the  effect  of  ttic  device 
it  is  intended  to  make  can  be  readily  understood. 

Tlie  bending  of  the  base-wire  is  most  easily  accomplished  with  a 
lai^e-sized  clasp-bender,  round-,  or  llat-noscd  pliers. 

There  are  two  kinds  of  base-wire,  the  ri(/kl  and  the  .Hprlnrj. 
Rigid  Base-Wire. — A  rigid  base-wire  is  necessarily  large  ;  it  should 
be  stiff  and  unyielding  to 
give  a  firm  foundation, 
to  which  si)rings  are  at- 
tached for  moving  the 
teeth  (Fig.  51 ).  The  size 
of  the  wire  employed 
generally  ranges  from 
No.  12  to  14,  B.  &  S. 
standard  wire  gauge, 
varying  according  to  the 
strength  and  rigidity  re- 
quired. 

Spring    Base-  Wire. — 
A    spring    base-wire    is 

one  that  serves  both  as  a  foundation  and  a  spring.  It  is  generally 
made  of  round  metal,  and  is  of  a  smaller  size  than  the  ordinary 
rigid  base-wire,  ranging  from  No.   15   to    12  gauge.     Usually   it  is 

formed  like  the  rigid  base- 
wire,  but  when  it  is  re- 
quired to  be  more  springy 
it  is  bent  into  one  or  more 
U-shaped  loops  (Fig.  52). 

Forms    of   Base-  Wire. — 
Three   forms   of  base- wire 
will  be  described, — the  Un- 
gual, labio-buccal,  and  j^ala- 
i<d  or  jjalafine.      They  are 
named    according    to     the 
location     in    the    arch    in 
which  they  are  to  rest. 
Lingual  Base-Wiir. — The   lingual   base-wire    is    applied    on    the 
lingual  side  of  the  teeth  of  the   lower  or  upper  arch.     It  should 
generally  be  shaped  to  follow  the  line  of  the  gum,  with  the  ends 

6 


82 


ANCHORAGE   AND   APPLIANCES 


Fig.  54. 


extending  Ijackward  on  either  side,  to  cross  one  or  more  partial- 
clasps,  to  which  it  is  soldered  \vith  the  ends  of  a  spring-clasp  for 
anchorage  (Fig.  53,  A).  The  lingual  base-wire  is  more  generally 
used  than  other  forms,  especially  for  apparatus  in  the  lower  arch. 

When  increased  rigid- 
ity of  the  apparatus  is 
required,  a  smaller  wire 
can  be  added,  shaped  to 
rest  close  to  the  teeth  a 
little  in  front  of  the  base- 
wire  and  united  to  it  with 
solder,  or  a  larger  sized 
wire  maybe  substituted. 
To  make  the  base- 
Avire  less  prominent 
when  the  appliance  is 
finished,  the  parts  that 
cross  the  partial-clasps 
can  be  flattened  on  the 
inner  side  by  dressing  with  a  corundum  stone  or  file  before  soldering. 
Lahio-Buccal  Base-Wire. — A  labio-buccal  base- wire  is  shaped  to 
cross  the  labial  and  buccal  side  of  the  teeth  near  the  gum,  with  the 
ends  extending  backAvard 
and  soldered  to  spring-clasp 
attachments  for  anchorage 
(Fig.  54). 

This  form  of  base-wire 
is  applicable  in  making 
apparatus  for  correcting 
certain  conditions  of  the 
occlusion  of  the  upper 
and  lower  teeth,  and  for 
the  purpose  of  retaining 
them. 

Palatal  or  Palatine  Base- 
Wire. — A    palatine    base- 
wire  is  one  that  extends  across  the  upper  arch  from  tlie  teeth  to 
be  used  for  anchorage  on   one  side,  following  the  palatine  curve, 
to  the  teeth  on  the  opposite  side,  with  the  ends  usually  bent  at  a 


BASE-WIRE  83 

right  angle  and  soldered  to  si)ring-clasp  attachments  for  anchorage 
(Fig.  55). 

The  palatine  base-wire  is  utilized  in  making  many  forms  of  ap- 
pliances for  the  upper  arch,  on  account  of  the  convenience  and  com- 
fort it  affords  the  patient,  as  well  as  for  increasing  the  rigidity  of  the 
apparatus.  It  can  be  used  to  especial  advantage  in  case  the  lower 
incisors  close  near  the  gum  on  the  palatal  side  of  the  upper  incisors, 
when  a  lingual  base-wire  would  interfere  with  the  tongue  in  the  pro- 
nunciation of  the  articulate  sounds  /,  c/,  and  s. 

Usually  sufficient  rigidity  is  gained  with  one  large  wire,  but  at 
times,  as  when  a  long  finger  spring  is  used,  it  is  an  advantage  to  add 
to  its  stiffness.  One  or  more  wires,  as  required,  may  be  formed  to 
run  parallel  with  the  base-wire  with  a  space  between  them,  or  to 
rest  close  together  and  be  united  with  solder  as  illustrated.  Any 
other  part  of  an  appliance  can  be  stiffened  in  a  similar  manner. 
In  uniting  the  wires,  a  more  satisfactory  result  is  occasionally  ob- 
tained by  fitting  a  thin  piece  of  partial-clasp  metal  underneath  them 
on  the  model  before  soldering.  If  three  wires  are  to  be  used  to- 
gether, the  two  outer  ones  should  be  of  smaller  size  and  united  with 
solder  in  the  same  manner  ;  or  the  base-wire  can  be  made  of  a  piece 
of  heavy  flat  metal. 

The  general  rigidity  of  an  apparatus  is  sometimes  best  attained 
by  utilizing  two  forms  of  base-wire  in  conjunction,  as  a  palatine 
base-wire  crossing  the  distal  part  of  the  arch  and  a  lingual  base-wire 
following  the  palatal  curve  of  the  anterior  teeth,  with  the  ends  of 
each  shaped  to  cross  the  partial-clasps  to  which  they  are  soldered 
for  anchorage.  The  palatine  base-wire  and  the  labio-buccal  base- 
wires  can  be  used  together,  or  the  labio-buccal  and  the  lingual  base- 
wires  can  be  utilized  when  the  conditions  require. 

Not  infrequently,  after  the  front  teeth  have  been  regulated,  it  is 
found  that  the  arch  needs  to  be  expanded  laterally.  When  a  lingual 
base-wire  has  been  used,  the  simple  bending  outward  of  the  sides 
of  the  base-wire  may  be  effective.  With  a  palatine  base-wire,  when 
only  slight  expansion  of  the  upper  arch  is  required,  the  base-wire 
can  be  straightened  a  little  at  a  time,  or  a  spring  base-wire  can  be 
inserted,  of  the  shape  illustrated  in  Fig.  97.  The  rigid  base-wdre 
can  be  converted  into  a  spring  base-wire  by  removing  a  section  from 
the  median  line  and  soldering  to  place  a  U-shaped  loop  of  similar 
metal  (Figs.  369,  370). 


84  ANCHORAGE  AND   APPLIANCES 

This  change  is  most  easily  made  by  passing  two  narrow,  short 
pieces  of  thin  partial-clasp  metal  underneath  the  base-wire  \vhen  the 
appliance  is  in  position  in  the  mouth,  placing  them  a  little  either 
side  of  the  median  line.  Then  take  an  impression  of  the  palatine 
part  of  the  arch  with  the  appliance  and  metal  in  place.  Remove  the 
impression  and  tlie  appliance  from  the  mouth  together.  Place  the 
pieces  of  plate-metal  in  position  in  the  impression,  and  run  a  model. 
Without  removing  the  appliance  from  the  model,  saw  a  section  from 
the  centre  of  the  base-wire  and  adjust  a  U-shaped  loop  of  the  same 
wire  metal.  Bend  the  thin  pieces  of  metal  around  the  ends  of 
the  loop  and  the  base-wire  and  unite  them  witli  solder.  The  loop 
should  be  made  narrower  from  side  to  side  tlian  the  shape  of 
the  arch  would  indicate,  to  permit  the  opening  of  the  loop  for  the 
necessary  expansion  of  the  arch  witliout  causing  undue  pressure  on 
the  soft  tissues  of  the  lateral  sides  of  the  vault. 

Teeth  best  suited  for  Anchorag-e. — As  a  rule,  the  anchorage 
should  include  more  teeth  in  number  than  those  to  be  moved.  In 
other  words,  the  teeth  for  anchorage  should  be  capable  of  resisting 
more  force  than  that  required  for  moving  the  irregular  teetli. 

Naturally,  the  teeth  most  firmly  set  in  the  arch  are  the  ones 
chosen  for  anchorage,  as  the  molars,  bicuspids,  and  cuspids.  Any 
of  the  teeth  may  be  employed.  The  anchorage  is  always  mucli 
more  complete  when  several  of  the  teeth  are  in  contact.  A  molar, 
owing  to  its  size  and  number  of  roots,  when  standing  alone  in  the 
process  is  generally  capable  of  resisting  a  force  sufficient  for  the  cor- 
rection of  one  or  more  irregular  incisors,  but  it  luight  not  be  suffi- 
cient for  the  movement  of  a  cuspid.  The  same  is  true  of  a  bicus- 
pid;  it  might  be  sufficient  for  the  movement  of  one  or  more  incisors, 
but  it  is  not  as  firmly  set  in  the  process  as  the  molar  and  is  a  less 
certain  anchorage.  The  cuspid,  owing  to  its  increased  length  and  the 
size  of  its  root,  is  sometimes  invaluable  for  the  purpose  of  anchorage. 
An  irregular  cuspid  has  been  known  to  resist  a  force  applied  from 
all  of  the  other  teeth  in  the  arch,  and  finally,  instead  of  itself 
yielding,  to  cause  their  movement. 

From  experience  it  is  found  that  a  spring-clasp  attachment  to  one 
tooth  on  each  side  of  the  arch,  in  connection  with  partial-clasps  on 
the  adjoining  teeth,  is  usually  sufficient  to  retain  and  anchor  an 
appliance. 

In  young  patients,  the  second  deciduous  molar,  when  firm  in  the 


TEETH   BEST  SUITED  FOR  ANCHORAGE 


85 


WM' " 


arch,  is  generally  utilized  for  anchorage  because  of  its  position  and 
shaix'.  The  rounded  contour  of  the  crown  is  especially  favorable 
for  retaining  with  the  spring-clasp  attachment.  The  diverging  roots, 
before  they  have  become 

absorbed,  afford  a  resist-  ^J°-  ^^• 

ance  for  this  form  of 
anchorage  equal  to  almost 
any  of  the  permanent 
teeth.  Its  degree  of  resist- 
ance will  be  readily  un- 
derstood by  those  who 
have  had  occasion  to  ex- 
tract one  of  these  teeth 
Avhile  the  roots  were  in- 
tact. From  its  position 
just  in  front  of  the  first 
permanent  molar  it  re- 
ceives sufficient  support  to  give  a  good  anchorage  for  moving  the 
incisors  outward,  etc.,  but  partial-clasps  should  be  adjusted  to  each  of 
the  adjoining  teeth  (Fig.  56).     With  this  arrangement,  although  but 

one  spring- clasp  attachment 
is  used  on  each  side  of  the 
arch,  the  adjoining  teeth  are 
included,  which  strengthens 
the  anchorage  and  steadies 
the  apparatus.  The  latter  is 
especially  necessary  when  the 
arch  is  to  be  expanded.  If  the 
appliance  is  to  draw  promi- 
nent incisors  into  line,  it  is 
advisable  to  have  the  base- 
wire  terminate  in  a  curve  on 
the  distal  surface  of  the  first 
permanent  molar,  or,  instead, 
to  have  a  smaller  wire  ex- 
tend from  the  base-wire  back  of  the  molar. 

In  an  adult,  where  the  bicuspids  and  the  first  and  second  molars 
are  erupted  (Fig.  57),  the  attachments  for  anchorage  should  be  to 
those  teeth  most  suitable  by  their  shape  and  location,  usually  to  one 


86  ANCHORAGE  AND  APPLIANCES 

of  the  bicuspids  or  the  first  molar  on  each  side  of  the  arch.  If  the 
second  molar  is  well  erupted,  a  stronger  anchorage  can  be  made  by 
forming  one  spring-clasp  attachment  to  it  and  another  to  the  second 
bicuspid;  or,  as  usually  preferable,  partial-clasps  may  be  adjusted  to 
all  of  the  teeth  to  be  used  for  anchorage,  with  spring-clasp  attach- 
ments to  the  first  bicuspid  and  first  permanent  molar,  and  the  base- 
wire,  or  a  smaller  wire,  made  to  extend  beyond  and  terminate  in  a 
curve  on  the  distal  side  of  the  second  molar. 

Teeth  not  fully  erupted,  or  with  a  portion  of  the  crown  lost  by 
decay,  can  be  utilized  for  anchorage  by  soldering  a  thin  piece  of 
plate-metal  to  the  anchorage  portion,  in  position  to  pass  between 
the  teeth,  and  thus  to  secure  a  good  attachment. 

When  a  tooth  that  is  not  fully  erupted  is  needed  for  anchorage, 
the  gum  can  be  pressed  away  from  it  in  some  instances,  separating  it 
sufficiently  towards  the  neck  for  the  application  of  a  partial-clasp  by 
forcing  between  the  gum  and  the  tooth  a  sterilized  cord,  or  a  small 
amount  of  sterilized  cotton,  or,  when  necessary,  tying  the  cord 
around  the  tooth  and  allowing  it  to  remain,  and  repeating  the  opera- 
tion at  intervals  several  times.  Generally,  however,  the  simple 
carving  of  the  model  will  suffice.  The  partial-clasp  used  for  this 
condition  should  be  made  of  a  thicker  metal  than  that  ordinarily 
used,  and  shaped  to  project  under  the  margin  of  the  gum.  In  solder- 
ing, the  part  that  is  to  extend  under  the  gum  should  be  kept  free 
from  solder. 

With  the  system  described  the  base-wire  can  be  anchored  to  the 
teeth  in  many  ways.  The  principal  method  employed  is  with  spring- 
clasp  attachments. 

In  some  cases  partial-clasps  are  used  independently,  especially  in 
the  lower  arch,  or  they  may  be  used  in  conjunction  with  points  of 
metal,  shaped  to  project  into  the  interdental  spaces,  usually  on  the 
sides  of  the  arch ;  or  the  appliance  may  be  retained  with  wire 
or  with  fiat  metal  clasps  passing  around  the  teeth.  Wire  springs 
have  been  employed,  passing  from  the  partial-clasps  and  base-wire 
over  the  grinding  surface  at  the  junction  of  the  teeth,  and  termi- 
nating in  the  form  of  hooks  to  rest  in  the  buccal  interdental  spaces ; 
or  the  ends  of  the  springs  may  be  left  longer  and  shaped  to  clasp  the 
surface  of  the  teeth  at  the  gum  line  for  anchorage. 

In  some  ca.sos,  when  the  anchorage  is  found  insufficient,  a  hole 
can  be  drilled  througli  the  parLial-clasp  at  the  junction  of  two  of  the 


WIRE-CLASP 


87 


Fig.  58. 


teeth  at  an  angle  suitable  for  the  introduction  of  a  short  screw,  or 

of  a  wire  soldered  in   place  to  extend  into  the  interdental   spaces 

near  the  necks  of  the  teeth.     Strips  of  plate-metal  can  be  bent  to 

hook  over  the  incisive  edge 

of  the  incisors  and  cuspids. 

In  an  emergency  the  appli- 
ance   may  be  retained  by 

cementing  it  to  place  with 

oxyphosphate,  or  by  pass- 
ing a   ligature   around  the 

base-wire  and  between  the 

teeth   used   for  anchorage, 

with  the   ends  tied  tightly 

to    the    outer  part   of  the 

spring-clasp  at  the  gum  line. 

Rather  than   continue  the 

use  of  the  ligature  in  any  case,  it  is  better  to  remake  the  appliance. 
Fig.  58  illustrates  an  anchorage  made  by  arranging  partial-clasps  on 

the  palatal  side  of  the  second  upper  deciduous  molars,  and  attach- 
ing to  each  a  unre-dasp. 
^^^-  59.  When  there  are  spaces 

between  the  teeth,  the 
wire-clasps  can  pass 
directly  around  to  the 
buccal  side.  If  the 
teeth  are  close  together, 
the  wire-clasp  may  be 
curved  to  pass  over  the 
grinding  surface  at  the 
junction  of  the  teeth 
and  bent  to  rest  on  the 
buccal  surface  of  the 
tootli  near  the  gum. 
The   remainder  of  the 

appliance  is  made  in  the  usual  manner,  with  base-wire  and  spring, 

the  parts  being  united  with  solder. 

Another  variation  from  the  regular  form  of  anchorage  is  shown  in 

Fig.  59.     When  the  device  is  adjusted,  it  admits  of  the  removal  of 

the  spring  without  removing  at  the  same  time  the  body  of  the  appa- 


88 


ANCHORAGE   AND   APPLIANCES 


Fig.  ()0. 


ratus.  The  latter  is  made  with  a  palatine  base-wire  and  spring- 
clasp  attachments  over  the  second  bicuspids,  with  partial-clasps  on 
the  first  molars  and  first  bicuspids.  A  tube  is  soldered  in  the  centre 
of  the  anchorage  portion,  on  either  side,  the  distal  end  of  the  tubes 
being  closed ;  or  a  slight  flange  is  placed  on  the  spring  to  prevent  it 
from  entering  the  tube  too  far.  A  semicircular  spring  for  moving 
the  teeth  is  bent  into  two  U-shaped  loops,  with  the  ends  shaped  to 
project  slightly  into  the  tubes  described.  Tubes,  eyelets,  or  hooks 
soldered  to  the  anchorage  portion,  base-wire,  or  to  spring-clasps, 
are  used. 

When  one  is  accustomed  to  the  use  of  opllars  for  anchorage,  this 
system  is  utilized  by  anchoring  a  base-wire  as  follows  :  A  collar, 
with  a  tube  soldered   on  the  lingual  side,  is  cemented  to  a  distal 

molar  and  to  one  of  the 
bicuspids  on  each  side  of 
the  arch.  The  tubes  can 
be  arranged  to  rest  horizon- 
tally or  perpendicularly.  A 
heavy  lingual  or  palatine 
base- wire  is  held  in  position 
by  soldering  to  it  a  small 
strong  wire  in  position  to 
enter  the  tubes.  Wires  en- 
tering the  tubes  on  the  mo- 
lars are  sometimes  arranged 
to  hook  into  the  tubes  from 
the  distal  end,  while  similar 
wires  are  attached  to  the  base-wire  to  enter  either  horizontal  or 
perpendicular  tubes  on  the  bicuspids.  When  tubes  are  arranged 
perpendicularly  on  the  collars,  they  are  generally  inclined  a  little 
either  forward  or  backward  to  improve  the  anchorage,  so  that  when 
force  is  applied  the  apparatus  will  not  become  dislodged.  A  labio- 
buccal  base-wire  is  anchored  in  a  similar  manner.  WIkmi  desirable, 
all  of  the  tubes  can  be  arranged  perpendicularly.  The  anchorage 
teeth  are  prevented  from  rotating,  when  extreme  stress  is  put  upon 
them,  by  soldering  the  tubes  on  the  mesio-lingual  or  the  disto-lingual 
surface  of  the  collar,  according  to  tlie  strain  to  be  applied. 

Fig.  60  illustrates  a  case  in  which  a  strong  anchorage  was  neces- 
sary.    TIh'    iippiT   cnsjjids    were   very   iiromincnt,  with   insufficient 


RE-ENFORCED  ANCHORAGE 


89 


space  for  their  correclion,  requiring  the  extraction  of  the  first  bicus- 
pids to  ])erinit  them  to  be  moved  into  the  circle.  The  lateral  incisors 
were  also  irregular,  needing  to  be  moved  outward  and  laterally. 
The  points  of  resistance  included  the  first  molars  and  second  bicus- 
pids, re-enforced  by  the  instanding  lateral  incisors.  At  that  time  the 
second  molars  were  not  sufficiently  erupted  to  assist  the  anchorage. 
An  ai)pliance  was  made  by  forming  a  spring-clasp  attachment  to  the 
first  molar  and  a  partial-clasp  on  the  second  bicuspid  on  either  side, 
soldered  to  a  lingual  base-wire  following  the  inner  curve  of  the  arch 
in  the  usual  manner.  Tlie  anchorage  was  fortified  by  shaping 
pieces  of  plate-metal  to  the  palatal  side  of  tlie  lateral  incisors  and 
uniting  them  with  solder  to  the  base-wire  near  the  gum.  In  this 
way  a   firm  anchorage   was   obtained.     The   cuspids   were  moved 

to    position    with    finger- 

^  ^  Fig.  (51. 

springs    attached    to    the 

partial-clasps  and  base- 
wire,  one  on  either  side 
of  the  arch,  after  which 
the  projecting  pieces  of 
plate-metal,  located  back 
of  the  laterals,  were  again 
utilized.  They  were  bent 
forward  slightly  from  time 
to  time,  causing  them  to 
act  as  inclined  planes  on 
the  laterals  for  moving 
them  outward  to  line. 

When  desirable,  the  anchorage  of  similar  appliances  can  be 
strengthened  by  cementing  to  one  or  more  of  the  front  teeth  a  collar 
with  a  narrow  lug  on  the  lingual  side,  in  position  to  engage  with  the 
base-wire  ;  or  wire-clasps,  shaped  to  encircle  the  second  bicuspids 
and  to  rest  on  the  buccal  side,  may  be  attached  to  the  base-wire. 
In  the  same  manner  wire-clasps  can  be  extended  backward  from  the 
base-wire  to  clasp  the  second  molars.  If  the  latter  are  only  jiartially 
erupted,  the  ends  of  the  springs  may  be  bent  sharply  upward  to  rest 
back  of  them  near  the  neck.  When  upper  incisors  require  to  be 
rotated  and  the  cuspids  drawn  backward,  with  the  lower  incisors 
impinging  against  the  gum  back  of  them,  a  device  as  illustrated  in 
Fig.  61   is  applicable.     The  base-wire  is  necessarily  placed  farther 


90 


ANCHORAGE  AND  APPLIANCES 


back  of  the  incisors  than  usual  to  prevent  interference  with  the  lower 
incisors  in  occlusion.  When  so  arranged,  the  anchorage  of  the  front 
part  of  the  appliance  can  be  made  firm  by  fitting  to  the  model  a 
piece  of  plate-metal,  shaped  to  extend  from  the  lingual  side  of  the 
incisors  backward  under  the  base-wire  to  which  it  is  soldered. 
Swaging  of  the  metal  is  not  usually  required.  The  distal  part  of 
the  appliance  should  be  well  anchored  with  partial-clasps  and  spring- 
clasp  attachments. 

When  a  molar  or  bicuspid  is  absent  the  anchorage  can  be  made 
with  a  spring-clasp  attachment  passing  over  a  tooth  on  either  side  of 
the  space.  It  is  sometimes  an  advantage  to  fill  the  space  with  an 
artificial  tooth  or  a  block  of  metal,  uniting  them  to  the  base-wire. 

After  the  loss  of  a  deciduous  molar,  a  permanent  molar,  or  a 
bicuspid,  there  is  a  tendency  for  the  erupted  and  non-erupted  back 
teeth  to  move  forward  and  occupy  some  of  the  space.  As  these 
teeth  move  forward  they  do  not  usually  move  bodily.  The  crowns 
are  broader  near  their  grinding  surface  where  they  rest  in  contact, 
and  when  they  are  pressed  upon  by  the  erupting  teeth  back  of  them 
they  are  gradually  tipped  forward  in  the  line  of  the  arch,  disarranging 
their  harmonious  occlusion  with  the  antagonizing  teeth.  For  this 
reason  teeth  should   not  be   extracted   for  the  purpose  of  making 

room    for  the    correction    of 
^^'  prominent    front    teeth    until 

about  the  time  when  a  regu- 
lating appliance  is  to  be  in- 
serted. The  open  sockets 
after  extraction  also  favor  the 
rapid  backward  movement  of 
the  teeth  in  front,  closing  the 
spaces. 

Fig.  62  illustrates  the  posi- 
tion of  the  teeth  of  a  boy  aged 
nine  years.  The  deciduous 
molars  were  extracted  too  early.  From  lack  of  support  the  first 
permanent  molars  had  moved  forward,  and  the  front  part  of  the 
arch  had  not  kept  pace  in  anterior  development  with  the  lower  arch, 
causing  the  upper  incisors  to  close  back  of  the  lower  ones.  This 
required  the  outward  movement  of  the  upper  incisors  to  articulate 
properly,  and  the  backward  movement  of  the  molars  to  make  room 


METAL   CAPS 


91 


for  the  erupting  second  bicuspids.  Anchorage  for  their  correction 
was  gained  by  a  spring-clasp  attachment  passing  over  each  of  the 
first  permanent  molars  connected  with  a  palatine  base-wire.  To  this 
was  attached  a  spring  with  a  semicircular  part  arranged  to  re^  on 
the  palatal  side  of  the  incisor  teeth  near  the  gum,  and  two  U-shaped 
loops  about  one-fourth  of  an  inch  long,  one  on  either  side  of  the 
arch  pointing  towards  the  median  line,  with  the  ends  of  the  spring 
soldered  to  the  partial-clasps  and  base-wire.  The  spring  was 
anchored  to  the  incisors  by  passing  under  a  lug  on  a  collar  cemented 
to  one  of  the  laterals,  and  under  another  lug  to  one  of  the  centrals. 
Opening  the  loops  in  the  spring  by  bending  caused  the  necessary 

Fig.  63. 


pressure  for  moving  the  incisors  outward,  and  at  the  same  time  the 
molar  teeth  were  gradually  forced  backward,  providing  space  for  the 
erupting  second  bicuspids. 

Metal  Caps. — The  methods  of  anchorage  described  are  usually 
sufficient,  but  sometimes,  in  special  cases,  there  may  be  an  advantage 
in  the  use  of  metal  caps,  one  on  either  side  of  the  arch,  the  cap 
being  properly  struck  up  to  fit  over  the  teeth  used  for  anchorage 
and  well  cemented  to  them  (Fig.  63).  A  continuous  metal  cap  can 
be  used  when  the  conditions  require.  When  partial  caps  are  em- 
ployed, they  should  cover  as  many  teeth  as  practicable,  with  tlie 
edges  extending  to  the  gum  on  the  buccal  and  lingual  sides.  The 
cap  is  stiffened  to  prevent  warping  by  soldering  to  the  edge  a  strip 


92 


ANCHORAGE   AND   APPLIANCES 


oi"  plate-metal  or  a  small  wire.  The  parts,  after  being  fitted,  can  be 
held  together  for  soldering  with  small  binding-wire  passing  through 
small  punch-holes  provided  in  the  cap.  When  there  are  spaces 
between  the  crowns  of  the  teeth  the  cap  can  be  further  stiffened  by- 
soldering  a  septum  of  thin  plate-metal  or  a  wire  across  the  inner  side. 
Any  suitable  apparatus  can  be  soldered  directly  to  the  cap,  or  at- 
tached by  means  of  eyelets^  hooks  of  wire,  tubes,  etc.,  soldered  to  the  cap. 
Cementing  Caps. — When  the  cap  is  shallow  the  inner  surface 
should  be  roughened  or  stippled  with  a  sharp  instrument  to  prevent 
its  separating  from  the  cement,  but  wdien  the  cap  is  deep,  stippling 
is  not  required.  In  adjusting,  the  teeth  should  first  be  cleansed, 
made  dry,  and  the  cap  held  firmly  in  place  until  the  cement  is  hard. 
When  properly  distributed,  the  cement  is  forced  into  the  depressions 
and  interdental  spaces,  covering  the  surfaces  of  the  teeth,  preventing 
injury  from  the  secretions,  and  giving  a  strong  anchorage. 

The  cap  can  sometimes  be  more  strongly  retained  by  passing  one 
or  more  small  wire  ligatures  between  the  teeth  and  through  holes  in 
the  labial  and  lingual  sides  of  it  wdien  cementing ;  the  ends  are  to 
be  fastened  by  twisting.  The  metal  of  the  cap,  if  thin,  does  not  in- 
terfere materially  with  the  occlusion. 

In  the  figure  is  seen  a  semicircular  spring  passing  in  front  of 
prominent  incisors  for  drawing  them  inward  to  line.  The  ends 
of  the  spring  are  bent  into  U-shaped  loops,  each  terminating  in  a 
hook  to  engage  with  an  eyelet  soldered  on  the  buccal  side  of  the 
caps.  The  eyelets  are  usually  made  of  wire  with  the  ends  extend- 
ing at  a  right  angle  in  opposite  directions  where  they  rest  on  the 
cap. 

A  metal  cap  for  the  anterior  part  of  the  arch  is  sometimes  employed 
as  anchorage  for  moving  other  teeth,  for  supporting  teeth  when  being 

moved  bodily,  and  for  retaining  teeth 
after  regulation  (Fig.  64). 

Owing  to  the  difficulty  in  swaging 

a  cap  for  the  incisors  and  cuspids,  it 

is     usually    more     satisfactory    when 

made    of   two    pieces   of  metal,   first 

swaging   with   metal    dies  a  piece  of 

plate  to  cov(.'r  the   labial  side  of  the  teeth,  with  the  metal  shaped 

to  project  a  little  over  the  margin  of  the  gum  and  the  incisive  edge 

of  the  teeth.     The  swaged  part  is  then  held  in  place  on  the  ])laster 


¥ui.  G4. 


PLATES 


93 


Fig.  65. 


model,  while  an  accurate  impres.sion  is  taken  (jf  tiie  palatal  side  of 
the  teeth  and  ed^^-e  of  the  metal.  From  this  other  dies  are  made,  and 
the  metal  swaged  as  before;  the  edge  of  each  part  is  trimmed  to 
fit  the  other  accurately,  and  held  together  with  wax.  The  parts  of 
the  cap  are  then  supported  with  plaster  and  sand,  and  soldered  in 
the  usual  manner. 

Improperly  anchored  regulating  appliances  sometimes  cause  un- 
desirable tipping  of  the  molars. 

It  is  important  that  teeth  used  for  anchorage  should  be  so  sup- 
ported that  they  will  remain  in  an  upright  position,  and  not  be 
changed  by  tlie  stress  put  upon  them.  To  accomplish  this,  as  many 
teeth  should  be  engaged  in  the  anchorage  as  can  well  be  employed, 
even  including,  when  necessary,  some  of  the  teeth  that  later  are  to 
be  moved  in  the  process  of  regulation.     (See  Fig.  60.) 

Plates. — The  following  figures  illustrate  the  use  of  plates  for  anchor- 
age. The  plate  covers  a  considerable  surface,  and  prevents  irritation 
when  severe  upward  or 
side  pressure  is  applied. 
It  has  tlie  advantage  in 
anchorage  gained  by  resting 
against  the  anterior  palatine 
arcli.  It  should  be  well  re- 
tained, so  that  it  will  not 
move  when  resisting  the 
force  necessary  in  regula- 
tion. 

The  plate  for  anchorage 
in  moving  bicuspids  is  illus- 
trated in  Fig.  65,  the  case 
of  Miss  M.,  aged  fourteen 
years.    The  teeth  were  very 

prominent,  with  no  spaces  between  them.  The  first  permanent 
molars,  being  decayed,  were  extracted  to  accommodate  the  bicuspids, 
which  were  moved  backward  in  tlie  arch  to  cause  room  for  the  in- 
ward movement  of  the  six  front  teeth.  The  plate  covered  the  pala- 
tine arch,  being  retained  by  fitting  well  the  necks  of  the  incisors, 
cuspids,  and  second  molars.  To  the  latter  it  was  further  secured 
with  wire-clasps.  A  curved  metal  spur  projected  from  either  side 
of  tlie  plate  to  rest  back  of  the  cuspids.     The  anchorage,  therefore, 


94 


ANCHORAGE  AND   APPLIANCES 


included  the  spurs,  the  attachment  to  the  second  molars,  and  the 
resting  of  the  plate  against  the  curve  of  the  anterior  palatine  arch 
and  the  necks  of  the  front  teeth.  This  is  usually  effective  in  pre- 
venting the  molars  from  moving  forward.  The  bicuspids  were 
forced  backward  with  finger-springs  located  in  the  centre  of  the 
plate  either  side  of  the  median  line.  The  free  ends  extended 
laterally  outward  and  rested  in  front  of  the  bicuspids,  passing  to  the 
buccal  side,  w^here  they  were  bent  forward  as  seen  at  a,  a.  The 
ends  of  the  clasps  and  springs  anchored  in  the  plate  were  first  flat- 
tened with  hammer  and  anvil  to  retain  and  prevent  them  from  ro- 
tatmg.  Only  a  small  portion  of  the  end  of  the  wire  should  be  flat- 
tened, as  it  is  found  that  it  is  not  so  easily  broken  in  bending  when 
embedded  a  considerable  distance  and  left  round  where  it  emerges 
from  the  vulcanite.  Swaged  or  cast  metal  plates  can  be  employed. 
In  this  case  the  bicuspids  were  large  and  their  movement  rather 
slow.     To  hasten   the   operation,   supplemental  force   was  applied 

by  an  external  apparatus  con- 
sisting of  a  cranial-cap  and 
cross-bar  device,  which  en- 
gaged with  the  free  ends  of  the 
springs  a,  a.  By  this  means, 
the  bicuspids  were  moved 
backward  to  the  required 
position  as  seen  in  Fig.  66  in 
a  limited  time.  For  further 
details  of  the  case  see  page 
398. 

In  Fig.  67  is  shown  a 
vulcanite  palatine  plate  for 
anchorage  that  is  suitable  for 
moving  backward  six  promi- 
nent upper  teeth,  or  a  less  number.  ^^  The  plate  is  retained  by  fitting 
well  the  necks  of  the  anchorage  teeth,  and  with  wire-clasps  about 
No.  19  gauge  extending  from  it  to  pass  around  a  molar  and  a 
bicuspid  on  each  side  of  the  arch,  as  seen  in  the  figure  ;  or  it  can  be 
retained  with  spring-clasps  of  No,  20  or  21  gauge  passing  over  the 
teeth,  the  clasps  being  shaped  similar  to  those  used  in  spring-clasp 


*  Jackson,  D.julal  Cosmos,  1888,  p.  510. 


PLATES  95 

attachments.  Clasps  of  the  shape  illustrated  are  usually  preferred, 
as  changes  to  fit  the  surface  of  the  teeth  are  more  readily  made. 

When  the  distal  molars  of  the  arch  are  not  well  erupted,  and 
when  the  gum  is  quite  prominent,  the  end  of  the  wire-clasp  may  be 
bent  upward  to  project  under  the  gum  towards  the  neck  of  the  tooth, 
or  it  can  be  arranged  to  pass  over  the  arch  at  the  junction  of  the 
teeth  to  clasp  the  one  next  in  front. 

When  the  central  incisors  are  more  prominent  than  the  laterals 
and  cuspids,  the  irregular  edge  of  the  plate  should  be  smoothed, 
and  the  portion  just  back  of  the  centrals  cut  away  a  little  to  permit 
their  inward  movement.  With  this  arrangement,  the  lateral  incisors 
and  cuspids  assist  the  anchorage  of  the  plate  until  at  a  later  time, 

Fig.  67. 


when  the  plate  back  of  these  teeth  is  also  dressed  away  a  little  for 
their  movement.  The  force  for  moving  the  incisors  is  supplied  by 
finger-springs  attached  in  the  plate,  one  on  either  side  of  the  arch. 
They  are  shaped  to  extend  to  the  buccal  side  in  front  of  the  second 
bicuspids,  and  curved  forward  to  rest  on  the  labial  surface  of  the 
incisors,  each  spring  extending  beyond  the  median  line ;  thus  they 
pass  one  another  and  serve  as  mutual  support.  Pressure  applied 
in  this  manner  on  tlie  central  incisors  alone  forces  them  inward 
towards  the  plate,  they  acting  as  a  wedge  between  the  adjoining  teeth, 
pressing  them  laterally  and  backward.     By  proceeding  in  this  way 


96 


ANCHORAGE   AND  APPLIANCES 


less  force  is  required  for  starling  all  of  tlie  six   front  teeth  in  their 
movement. 

In  some  forms  of  ancliorage  witii  the  plate,  where  slight  pressure 
is  required,  it  can  be  held  in  position  by  suction,  being  fitted  well  to 
the  necks  of  the  teeth.  In  other  cases  one  or  more  spring-clasps 
may  be  anchored  in  the  plate  on  either  side,  shaped  to  extend  over  the 
arch  at  tlie  junction  of  two  of  the  teeth  to  the  buccal  side,  and  termi- 
nating in  a  hook  to  i)roject  into  the  interdental  spaces.  Or  a  collar 
with  a  lug  attached  can  be  cemented  to  a  molar  or  bicuspid  on 
either  side  of  the  arch,  the  lug  being  shaped  to  project  slightly  over 
the  plate  when  pressed  into  place. 

When  the  plate  is  used  for  retaining  incisors  that  Jiave  been 
moved  outward,  it  is  often  necessary  to  cement  to  each  of  them 

a  collar  with  a  strong  lug  on 
the  palatal  side,  shaped  to 
project  over  the  edge  of  the 
plate  for  anchorage.  The  lug 
always  should  project  at  a 
right  angle  with  the  long  axis 
of  the  tooth. 

Fig.  68  illustrates  a  modified 
Coffin  split  plate,  anchored 
with  spring- clasps,  passing 
over  a  first  bicuspid  and  first 
molar  on  either  side  of  the 
arch.  Wire-clasps  can  be 
used  when  preferred.  If  the  teeth  are  not  well  developed,  the 
model  should  be  carved  to  lengthen  them,  forming  a  groove  as 
in  the  application  of  partial-clasps,  the  rubber  being  extended  well 
up  about  the  neck. 

External  Anchorage. — Anchorage  secured  by  the  attachment  of 
apparatus  to  available  teeth  in  the  dental  arch  is  sometimes  not 
sufficient  to  resist  the  force  necessary  for  correcting  the  position  of 
irregular  teeth  in  other  parts  of  the  arch.  For  instance,  in  cor- 
recting protrusion  of  tlie  permanent  upper  incisors,  before  the 
eruption  of  the  second  i)ermanent  molars  or  the  biscupids,  with  the 
deciduous  molars  absent,  we  have  only  the  Hrst  permanent  molars 
to  serve  as  ancliorage  for  moving  inward  all  of  the  front  teetli ; 
again,  wlien  the  first  permanent  molars  are  lost  from  decay,  in  the 


Fig.  09. 


Fig.  70. 


EXTERNAL  ANCHORAGE  97 

correction  of  anterior  protrusion,  the  second  permanent  molars  are 
tlio  only  available  teeth  for  anchorage. 

The  necessity  of  additional  ancliorage  for  moving  the  teeth  in 
similar  cases  prompted  Dr.  Kingsley,  in  1865,*  to  devise  a  method 
of  utilizing  the  back  of  tlie  head  for  anchorage  with  a  cap,  making 
the  attachment  to  the  teeth  with  a  gold  frame  and  external  bars. 

I  employ  a  cap  for  anchorage,  as  seen  in  Fig.  69,  which  I  term  a 
cranial-cap.  It  is  made  of  a  heavy  netting  or  with  large  silk  twist, 
crocheted  usually  around  a  connnon  centre,  leaving  meshes  about 
one -half  inch  square.  This  is  supported  by  a  band  of  silk  ribbon 
one  and  one-half  inches  wide,  the  ribbon  being  doubled  upon  itself 
to  enclose  the  edge  of  the  crocheted  part  to  which  it  is  sewed.  The 
band  should  be  sufficiently  large  to  rest  loosely  about  the  head, 
letting  all  of  the  strain  come  on  the  netting  when  force  is  applied. 
If  fitted  tightly,  it  is  liable  to  cause  discomfort.  To  the  band  are 
sewed  suspenders  of  the  same  ribbon  material,  usually  four  in 
number,  one  located  just  back  of  each  ear  and  another  considerably 
in  front,  the  exact  location  of  their  attachment  being  determined  by 
the  direction  of  the  traction  required.  The  part  of  the  suspender 
united  to  the  band  is  broad,  while  the  lower  portion  is  narrow  and 
of  a  uniform  width  to  pass  easily  through  a  small  buckle.  To  the 
buckles  are  attached  hooks  for  supporting  elastic  bands.  In  at- 
taching the  hook,  a  rather  stiff  piece  of  plate-metal,  usually  of 
German  silver,  as  wide  as  the  buckle  and  about  one  inch  long,  is 
passed  around  the  bar  of  the  buckle  and  united  to  it  with  solder. 
To  the  back  of  the  metal,  resting  towards  the  cheek,  is  soldered  a 
large  hook  of  wire,  or  a  hook  purchased  in  the  market  as  "  hooks 
and  eyes."  If  preferred,  the  hook  can  be  soldered  directly  to  the 
buckle.  When  in  use  the  elastic  bands  are  stretched  over  knobs 
on  a  cross-bar  device  connected  with  the  teeth.  Thick  rubber 
bands  of  pure  gum,  about  five-eighths  of  an  inch  in  the  inner 
diameter,  give  the  best  satisfaction.  Sections  cut  from  pure  gum 
tubing,  inner  diameter  about  one-fourth  inch,  have  been  satisfac- 
torily employed. 

The  advantage  of  the  use  of  the  buckle  in  connection  with  rubber 
rings  for  making  definite  changes  of  pressure  is  apparent. 

The  cranial-cap  is  placed  well  back  on  the  head  when  used  for 

*Kingsley's  Oral  Deformities,  p.  134. 

7 


98  ANCHORAGE  AND  APPLIANCES 

reducing  anterior  protrusion  of  the  upper  or  lower  incisors,  for 
moving  inward  upper  or  lower  cuspids,  for  moving  cuspids,  bicuspids, 
or  molars  backward  in  the  line  of  the  arch,  and  for  the  reduction  of 
prognathism.  It  is  to  be  placed  forward  on  the  head,  thus  drawing 
more  upward,  when  used  for  depressing  extruded  upper  incisors, 
for  correcting  lack  of  anterior  occlusion,  for  improving  the  general 
occlusion  of  the  teeth,  and  for  preventing  mouth-breathing. 

Cross-Bar. — A  cross-bar  is  a  bar  of  metal  curved  to  cross  in 
front  of  the  face,  with  the  centre  pivoted  or  hinged  to  apparatus 
passing  over  the  teeth  or  to  a  chin-cap.  It  is  used  in  connection 
with  a  cranial-cap  for  causing  force  in  regulating.  Each  end  of  the 
bar  is  provided  with  one  or  two  small  knobs,  over  which  are  hooked 
rubber  bands.  Generally  the  cross-bar  is  made  by  uniting  two  bars, 
m  the  centre,  with  the  ends  separated  a  little  to  improve  the  line  of 
traction. 

Fig.  69  illustrates  a  cross-bar  of  German  silver  spring-wire,  about 
No.  8  B.  &  S.  gauge.  Any  suitable  material  can  be  used.  A 
tin  or  lead  wire  is  first  shaped  approximately  in  the  form  of  the- 
cross-bar  desired.  Placing  it  before  the  face,  note  the  length  of  the 
arms  and  the  width  between  them,  with  the  two  arms  near  together 
at  the  centre  or  median  line,  diverging  gradually  to  about  one  and 
one-half  inches  apart  at  either  end,  where  it  is  formed  into  a  shallow 
loop.  Then  place  the  wire  on  a  paper  and  make  a  pencil  tracing  by 
marking  either  side  of  it,  thus  forming  a  pattern,  over  which  the 
wire  cross-bar  can  be  shaped.  The  two  ends  of  the  wire  are  to  be 
arranged  to  meet  in  the  centre  of  the  bar,  and  united  with  silver 
solder  to  a  narrow  piece  of  heavy  German  silver  plate  about  one 
inch  long.  At  the  same  time  attach  to  the  inner  surface  and  centre 
of  the  plate  a  short  piece  of  large  wire,  usually  bent  at  a  right  angle 
and  formed  into  a  post  about  three-eighths  of  an  inch  long,  flattened 
laterally,  with  a  hole  drilled  near  the  free  end  for  the  passage  of  a 
pin  for  hinging  it  to  a  trough-shaped  device  passing  over  the  incisor 
teeth.  To  the  end  of  each  of  the  arms  on  the  corners  of  the  cross- 
bar is  soldered  a  metal  knob  three-eighths  of  an  inch  or  more  in 
diameter,  and  suitably  formed  for  the  attachment  of  rubber  rings. 

For  changing  the  line  of  traction  with  the  suspenders,  the  loop 
part  of  the  wire  at  the  ends  of  the  cross-bar  can  be  bent  to  draw 
the  arms  closer  together  or  straightened  to  force  the  arms  farther 
apart  (Fig.  70). 


CRANIAL-CAP— CROSS-BAR 


99 


The  latter  is  also  an  advantage  in  preventing  the  suspender  from 
resting  against  the  ear. 

Improved  Cross-Bar. — An  improved  adjustable  cross-bar  is  shown 
in  Fig.  71.  In  making  it,  a  i)ioco  of  German  silver  about  one  inch 
long,  one-half  inch  wide,  and  tliree-sixteenths  of  an  inch  thick, 
termed  a  centre-piece,  is  employed.  In  the  centre  of  one  side  a 
threaded  hole  is  cut  for  the  adjustment  of  a  post  about  three-eighths 
of  an  incli  long  («),  and  two  holes  are  drilled  in  eacli  end  for  the 


Fig.  71. 


adjustment  of  arms  of  spring-wire,  about  No.  8  B.  &  S.  gauge,  and 
fastened  with  soft  solder.  The  length  of  the  arms  is  determined  by- 
shaping  them  to  the  face,  leaving  them  sufficiently  long  to  prevent 
pressure  on  the  cheeks  from  suspenders  extending  from  a  cranial- 
cap.  The  arms  diverge  to  about  one  and  one-half  to  two  and 
one-half  inches  at  their  outer  ends,  where  they  are  flattened,  and 
a  threaded  hole  cut  in  each  for  the  insertion  of  a  screw  supporting 
a  knob.  The  ends  of  the  arms  are  connected  and  made  more 
rigid  by  a  stay-piece,  made  of  a  bar  of  rather  stiff  plate-metal, 
about    one-fourth    of   an    inch  wide,   with    a    hole    in    either   end, 


100  ANCHORAGE  AND  APPLIANCES 

through  which  the  knobbed  screws  are  passed  when  turned  to 
place,  clamping-  them  to  the  arms.  A  longer  or  shorter  stay-piece 
can  be  inserted  for  miproving  the  lines  of  traction,  or  extra  threaded 
holes  can  be  made  in  the  stay-pieces,  or  in  one  or  both  of  the 
bars.  The  cross-bar  is  used  in  depressing  the  upper  incisors  and 
for  moving  them  inw^ard  by  hinging  the  post  (a),  as  described,  to 
apparatus,  or  to  a  removable  trough-shaped  device  passing  over 
the  teeth  (e).  This  device  is  made  of  a  piece  of  stiff  sheet-metal 
about  three-fourths  of  an  inch  wide,  and  long  enough  to  be  curved 
and  to  cross  the  labial  side  of  two  or  more  of  the  incisors  as  desired, 
usually  reaching  on  to  the  cuspids.  One  edge  of  the  metal  is 
arranged  to  rest  near  the  gum.  From  the  other  edge,  projecting 
below  the  incisors,  are  cut  V-shaped  pieces  opposite  the  line  of  the 
junction  of  the  teeth  and  reaching  to  the  incisive  edge,  as  shown  at 
b.  The  remaining  sections  of  the  metal,  corresponding  to  the  teeth, 
are  curved  backward  to  pass  over  them  and  rest  on  the  lingual  side 
(c).  To  stiffen  the  metal  a  small  wire  is  soldered  around  the  upper 
edge  and  ends. 

A  socket  is  made  by  bending  a  narrow  strip  of  plate-metal  in  the 
shape  of  a  horseshoe,  with  the  inner  diameter  a  little  more  than 
that  of  the  post. 

On  the  inner  side  at  the  end  is  soldered  a  wire  of  small  size  to 
form  a  flange.  The  other  end  is  attached  with  solder  to  the  front 
of  the  device,  near  the  lower  edge  at  the  median  line.  The  post  is 
held  in  place  in  the  socket  by  a  pin  which  is  passed  through  holes 
in  the  lateral  sides  near  the  entrance,  the  ends  of  the  hole  through 
the  post  (a)  being  reamed  to  permit  a  rocking  motion.  The  cross- 
bar, hinged  in  the  centre  in  this  way,  acts  like  a  whiffle-tree,  always 
bearing  in  a  direct  line,  even  when  one  end  of  the  bar  is  disturbed 
by  the  patient  in  sleeping  on  the  side. 

Dr.  C.  L.  Goddard*  constructs  a  cross-bar  by  making  a  vulcanite 
cap  to  pass  over  the  teeth  to  be  moved,  fitted  to  the  labial  and  to 
a  part  of  their  lingual  surfaces,  the  vulcanite  enclosing  a  bow-shaped 
wire  bar,  with  each  end  curved  into  the  form  of  a  hook. 

Chin-Cap. — A  chin-cap  (Fig.  72)  is  made  as  follows:  An  impres- 
sion of  the  chin  is  first  taken,  as  described  in  Ciiapter  IV.,  Impressions, 
and  a  model  made,  from  wliich  a  die  and  a  counter-die  are  prepared. 


*  Goddard,  American  Text-Book  of  Dentistry,  p.  624. 


Fig.  72. 


^.'.      ^ 


CHIN-CAP  101 

It  is  advisable  to  make  a  pattern  a  little  larger  than  the  chin-cap 
required. 

A  sheet  of  metal,  usually  of  German  silver,  about  No.  25  gauge, 
is  shaped  with  tlie  fingers  to  the  front  part  of  the  die,  with  the  centre 
at  the  prominence  of  the  chin.  Two  cuts  are  then  made  in  the  pro- 
jecting side,  towards  the  centre,  approaching  one  another  within 
about  three-fourths  of  an  inch.  The  central  separated  part  is  then 
bent  downward  over  the  die  to  rest  underneath  the  chin,  and  the 
parts  on  eitlier  side  are  bent  backward  to  overlap  the  central  portion, 
and  also  to  rest  under  the  chin.  The  projecting  excess  of  metal  is 
cut  away,  leaving  a  sufficient  lap.  It  is  then  further  shaped  to  the 
die,  swaged,  and  soldered  with  silver  or  German  silver  solder. 

To  the  front  and  lower  portion  of  the  cap,  crossing  it  horizontally, 
are  attached  two  curved  wires  No.  8  gauge,  either  square  or  round, 
about  two  and  one-half  inches  long,  and  half  an  inch  apart  at  the 
centre,  with  the  ends  diverging  and  soldered  to  the  cap,  for  stiffening 
it  and  forming  a  hinge.  The  wires  are  best  held  for  soldering  by 
fastening  them  with  binding-wire,  passing  it  through  small  holes  in 
the  cap  provided  for  the  purpose.  Through  each  of  the  curved 
wires  a  hole  is  drilled  perpendicularly  at  the  median  line  for  the  in- 
sertion of  a  pin  in  hinging  the  centre-piece  of  a  cross-bar.  A  cross- 
bar, as  in  Fig.  71,  is  attached  to  the  chin-cap,  with  the  centre-piece 
made  as  illustrated  at  d,  the  inner  side  being  thickened  in  the  form 
of  a  ridge  crosswise,  through  which  a  hole  is  drilled,  and  connected 
to  the  chin-cap  with  a  pin. 

The  cross-bar  attached  to  the  chin-cap  in  this  manner  applies 
direct  force  at  the  point  of  the  chin,  and  at  the  same  time  permits  a 
rocking  motion  which  is  desirable,  preventing  interference  or  dis- 
placement of  the  cap  when  the  patient  is  lying  on  the  side. 

When  the  chin-cap  is  used  for  reducing  prognathous  conditions, 
the  cranial-cap  is  usually  placed  far  back  on  the  head  to  get  the 
necessary  line  of  traction,  and  the  arms  of  the  cross-bar  are  shaped 
accordingly ;  but  when  the  chin-cap  is  used  to  correct  lack  of  occlu- 
sion, improving  the  general  occlusion  of  the  teeth,  or  to  prevent 
mouth-breathing,  the  traction  should  be  more  directly  upward,  and 
the  cranial-cap  is  necessarily  placed  far  forward  on  the  head,  being 
made  sufficiently  large,  with  the  anterior  suspenders  attached  well 
towards  the  front,  and  the  posterior  suspenders  placed  back  of  the 
ears.       This    changed    direction   of    traction  usually   necessitates   a 


102  ANCHORAGE   AND   APPLIANCES 

change  in  the  shape  of  the  arms  of  the  cross-bar  to  prevent  tippmg 
of  the  chin-cap. 

With  the  improved  cross-bar,  the  change  is  made  by  removing 
the  stay-pieces  and  replacing  them  after  bending  upward  or  down- 
ward the  arms  of  the  cross-bar,  or  by  separating  more  the  ends  of 
the  arms  and  introducing  longer  stay-pieces,  clamping  them  with 
the  knobbed  screws  as  before.  The  chin-cap  should  be  lined  with 
chamois,  cottonoid,  linen,  or  other  comfortable  material. 

Dr.  Geoi^e  S.  Allan,  recommending  the  use  of  the  chin-cap  in  1878,* 
tells  how  to  solder  two  arms  across  the  cap,  with  the  ends  curved 
into  hooks  for  the  attachment  of  elastic  ligatures,  the  arms  being 
bent  as  desired. 

External  Supplemental  Anchorage. — The  cranial-cap,  with  a  cross- 
bar as  supplemental  anchorage,  in  connection  with  apparatus  in  the 
mouth,  is  used  for  moving  inward  jDrominent  upper  or  lower  incisors 
to  reduce  anterior  protrusion,  moving  inward  prominent  upper  or 
lower  cuspids,  and  moving  cuspids,  bicuspids,  or  molars  backward  in 
the  line  of  the  arch.  A  chin-cap  and  wire-standards^  supported  by  a 
cranial-cap,  are  used  for  moving  outward  or  inward  the  incisors  and 
cuspids,  moving  the  bicuspids  and  molars  forward  or  backward  in 
the  line  of  the  arch,  and  for  elevating  or  depressing  the  teeth. 
Each  of  these  operations  is  further  referred  to  in  future  chapters. 

External  Independent  Anchorage. — The  cranial-cap,  as  independent 
anchorage,  is  used  with  a  cross-bar  for  depressing  extruded  upper 
incisors ;  in  connection  with  a  chin-cap,  for  depressing  extruded 
lower  incisors ;  for  the  reduction  of  prognathism,  the  correction  of 
lack  of  anterior  occlusion,  improving  the  general  occlusion  of  the 
teeth,  preventing  mouth-breathing,  etc.  (For  further  reference,  see 
chapters  on  these  subjects.) 

Springs. — Springs  for  moving  the  teeth  should  be  made  of  a 
tenacious  metal,  capable  of  being  bent  many  times  without  break- 
ing. Spring  gold,  platinoid,  German  silver,  or  any  springy  metal 
can  be  used  for  this  purpose,  preference  being  given  to  the  metals 
least  liable  to  oxidation,  and  to  those  the  temper  of  which  is  least 
affected  by  the  heat  required  in  soldering. 

Platinoid  and  German  silver  wire  as  sold  in  the  market  vary  in 
quality.     Two  grades  of  temper  are  generally  kept  in  stock  by  the 

*  Allan,  Transactions  of  the  New  York  Ddontological  Society,  1878. 


SPRINGS  103 

dealer,  the  springy  and  the  soft.  The  spring-wire  is  made  by  drawing 
the  softer  wire  through  a  draw-plate  until  it  becomes  of  the  desired 
hardness.  If  overdrawn,  it  becomes  brittle,  breaks  easily,  and  is 
not  suitable  for  making  springs  with  sliarp  curves ;  therefore  a 
medium  hardness  of  wire  should  be  used  for  springs  that  need  to  be 
bent  many  times,  and  when  there  is  not  sufficient  spring,  the  wire 
can  be  redrawn  or  well  burnished,  which  will  make  it  of  better 
temper  or  more  springy.  Piano-wire  is  very  tenacious,  and  has 
superior  spring  properties.  Springs  of  piano-wire  have  been  used 
successfully  in  connection  with  vulcanite  plates.  It  has  been  used 
for  springs  and  spring-clasps  in  all  metal  appliances,  but  I  have 
nearly  abandoned  its  use  for  the  latter  owing  to  its  tendency  to  cor- 
rode. It  can,  however,  to  some  extent  be  protected  from  corrosion 
by  dipping  the  spring,  after  making  it  of  the  desired  shape,  into  a 
solution  of  muriate  of  zinc,  and  then  into  molten  tin,  which  forms  a 
coating.  Electroplating  steel  wires  with  copper  and  gold  has  not 
proved  satisfactory,  as  the  plating  is  not  impervious  to  the  secretions. 
Plating  or  gilding  on  platinoid  and  German  silver  springs  wears  well 
in  connection  with  rubber  plates.  When  soft  solder  is  used  for 
uniting  all  metal  appliances,  in  some  cases  the  gold  plating  does  not 
give  good  satisfaction,  owing  to  the  chemical  action  caused  by  acidity 
of  the  secretions. 

The  round  spring-wire  (Fig.  73)  is  usually  preferred,  as  it  can  be 
bent  at  any  angle,  which  as  already  said  cannot  be  done  witli  a  wire 
in  any  other  shape  ;  also  the  round  wire  comes 
less  in  contact  with  the  teeth,  and  does  not  ^^^-  "3. 

retain  the  secretions  like  the  flat  or  square 
wire.  For  some  uses,  however,  the  latter 
may  be  preferable. 

Size  of  Springs. — The  size  of  the  spring  should 
vary  according  to  the  length  and  amount  of 
force  required.  The  numbers  most  commonly 
used  for  this  purpose  range  from  17  to  22  B. 

&  S.  gauge.  The  bending  is  done  with  the  clasp-bender,  the  round- 
or  the  flat-nosed  pliers.  When  the  metal  is  brittle,  to  prevent  break- 
ing it  should  be  bent  slowly,  and  not  at  an  acute  angle,  but  be  shaped 
into  gentle  curves.  Sometimes  the  metal  can  be  softened  in  these 
parts  with  a  low  flame  to  prevent  breaking,  and  not  interfere  detri- 
mentally with  the  spring  properties. 


104  ANCHORAGE  AND  APPLIANCES 

Form  of  Springs. — Springs  can  be  made  in  any  form  desired ; 
such  as  the  long  and  short  fmger-spring,  the  curved  fmger-spring, 
and  the  semicircular  spring  with  the  U-shaped  loops  (Figs.  60,  62, 
65,  67).  Many  other  forms  of  springs  will  be  described  in  this 
work. 

Occasionally  a  secondary  spring,  flat  or  round,  can  be  attached 
with  advantage  to  the  first  spring,  either  for  elongating  it  or 
extending  at  an  angle  from  it  for  a  special  purpose.  The  elongation 
of  a  finger-spring  in  this  manner,  to  keep  pace  with  the  movement 
of  a  tooth,  is  easily  accomplished  by  soldering  a  piece  on  to  the  end 
of  the  spring;  or  the  parts  can  be  made  adjustable,  as  seen  in  Fig. 
142.  This  is  done  by  soldering  two  rings  of  plate-metal,  or  short 
sections  from  a  tube,  to  the  end  of  a  short  piece  of  spring-wire, 
leaving  a  space  between  them,  and  so  arranging  them  that  they  will 
slip  over  the  end  of  the  spring  that  is  to  be  lengthened.  The  tubes 
should  fit  closely,  or  be  bent  together  to  prevent  slipping. 

A  long  spiral  spring  with  the  end  shaped  to  engage  with  a  tooth 
has  been  used  to  advantage  in  connection  with  a  base-wire,  attach- 
ing it  at  the  side  or  passing  the  base-wire  through  it. 

Springs  can  be  made  to  extend  either  from  a  lingual  or  palatine 
base-wire  or  from  a  plate  in  any  curve  necessary  for  moving  the 
teeth  outward,  or  in  any  form  desired  to  reach  over,  or  through  a 
space  to  the  outer  side  of  the  arch  for  moving  the  teeth  inward.  The 
best  form  of  spring  can  be  determined  by  shaping  soft  tin,  lead,  or 
copper  wire  to  the  model.  In  some  instances  it  is  an  advantage  to 
trace  with  a  pencil  on  card-board  the  form  obtained  with  the  lead 
wire,  bending  the  spring  in  a  similar  shape. 

The  attachment  of  Hpr'mfjs  is  usually  made  with  solder  to  a  base- 
wire  or  partial-clasp,  but  occasionally  a  spring  is  made  more  service- 
able by  being  attached  to  a  spring-clasp.     (See  Soldering.) 

A  base-wire  spring  is  necessarily  larger  than  the  ordinary  spring, 
as  it  serves  as  a  base-wire  to  keep  the  appliance  in  form,  and  at  the 
same  time  acts  as  a  spring  to  move  the  tec'lh  (Fig.  52). 

The  sizes  most  employed  for  base-wire  springs  range  from  12  to 
15  B.  &  S.  gauge.  These  and  other  forms  of  springs  will  be 
described  in  connection  with  appliances. 

In  arranging  the  base-wire  spring  to  cross  the  palatine  arch  for 
any  purpose,  it  is  essential  that  it  be  shaped  io  interfere  as  little  as 
possible  with   the  tongue  in    jjronniiciation,  ])assiiig  close  to  the  in- 


FORM    AND   ATTACHMENT  OF  SPRINGS  105 

cisor  teeth,  or  crossing  the  arch  considerably  back  of  them,  following 
the  palatine  curve,  thus  avoiding  the  part  that  the  tongue  touches  in 
making  the  sounds  t,  d,  and  s.  When  the  spring  is  to  have  a  twist- 
ing strain,  the  attachment  for  ancliorage  is  strengthened  in  some 
instances  by  flattening  the  end  before  soldering,  bending,  or  turning 
the  end  upon  itself. 

Generally  it  is  an  advantage  to  exert  such  force  as  will  move  the 
teeth  slowly,  although  often  no  harm  will  result  from  a  more  rapid 
movement. 

Attachment  of  Springs  to  Plates. — In  attaching  a  round  spring  in  a 
vulcanite  plate,  the  end  sliould  first  be  flattened  on  an  anvil  with  a 
hammer,  to  retain  it  firmly  in  the  rubber  and  prevent  it  from  twist- 
ing. The  flattened  portion  of  the  spring  should  not  reach  to  the 
surface  of  the  vulcanite,  as  it  is  found  to  be  much  stronger  if  left 
round  where  it  emerges  from  the  plate. 

An  adjustable  attachment  of  springs  either  to  a  metal  or  a  vul- 
canite plate  is  occasionally  an  advantage.  A  convenient  method  is 
to  square  the  end  of  a  spring  either  by  filing  or  by  the  addition  of 
solder,  and  fitting  carefully  around  its  surface  a  thin  piece  of  metal 
plate-material  forming  a  ferrule,  which  can  be  placed  in  proper  posi- 
tion in  the  try-plate  to  be  vulcanized,  or  the  ferrule  may  be  soldered 
to  the  surface  of  a  metal  plate.  The  spring  can  then  be  fastened  in 
the  ferrule  with  shellac,  which  can  again  be  easily  softened  by  warm- 
ing the  spring  and  removing  it  for  the  necessary  changes. 

It  frequently  occurs,  when  regulating  with  rubber  or  metal  plates, 
that  an  extra  spring  is  needed  temporarily  to  complete  the  work, 
A  spring  may  be  attached  for  this  purpose  by  passing  it  through  a 
hole  in  the  side  of  the  plate,  the  end  flattened  and  formed  to  fit  the 
surface,  and  fastened  by  drawing  binding-wire  through  other  holes 
in  the  plate  either  side  of  the  flattened  wire  and  twisting  the  ends 
together,  or  uniting  them  with  solder.  A  spring  can  be  attached 
directly  to  a  metal  plate  with  soft  solder. 

Another  method  is  to  solder  a  piece  of  metal  to  the  end  of  a 
spring,  as  seen  in  Fig.  74,  and  rivet  it  to  the  plate.  The  wire  is 
flattened  on  the  end  usually  without  drawing  the  temper,  and  a  thin 
piece  of  German  silver  or  other  metal,  about  one-fourth  of  an  inch 
or  less  in  size,  is  contoured.  The  flattened  end  of  the  wire  is  then 
attached  in  the  contoured  portion  with  soft  solder.  The  edge  of  the 
metal  is  trimmed  to  the  desired  form,  and  holes  punched  with  the 


106 


ANCHORAGE  AND   APPLIANCES 


plate  punch  or  drilled  in  the  sides  for  rivets,  \vhich  are  made  to 
pass  through  the  plate.  The  common  pin,  with  the  temper  drawn, 
is  a  convenient  rivet  to  fasten  the  springs,  by  riveting  or  soldering 
with  soft  solder.     A  method  that  has  been  used  to  advantage  in  an 


Fig 


emergency  is  to  flatten  the  end  of  a  spring,  fit  it  to  the  plate,  and 
drill  several  holes  either  side  of  it,  through  which  rivets  or  ordinary 
pins  are  passed ;  the  heads  of  the  rivets  are  counter-sunk  in  the  op- 
posite side  of  the  plate,  with  the  ends  of  the  rivets  bent  over  the 
flattened  spring  and  attached  with  soft  solder.  A  band  or  clasp  of 
any  suitable  metal  can  be  soldered  to  the  free  end  of  a  spring  to 
hold  it  in  place  on  the  tooth  to  be  regulated,  in  the  manner  shown 
in  the  figure. 

A  simple  means  of  keeping  the  spring-wire  from  pressing  on  the 
gum,  or  slipping  off  the  teeth  when  regulating  the  molars  or  bicus- 
pids, is  to  twist  small  wire  around  the  end  of  a  spring,  tacking  it 
with  soft  solder.  It  is  usually  applied  by  having  one  end  shorter,  to 
project  into  the  interdental  space,  while  the  other  end  is  a  little 
longer,  to  rest  on  the  grinding  surface  at  the  junction  of  the  teeth. 
(For  Action  of  Spring,  see  page  113.) 

Collars. — A  collar  (band)  is  a  thin  piece  of  metal  shaped  to  fit 
around  a  tooth,  with  the  ends  united.  The  earlier  use  of  the  collar, 
band,  ferrule,  or  clasp  was  for  tlie  anchorage  of  long  bands,  plates, 
and  inclined  planes.  Harris,  in  1839,  described  a  method  of  rotating 
incisors  by  means  of  a  carefully  adjusted  gold  band,  which  he 
stamped  between  a  die  and  a  counter-die.  To  the  labial  and  palatal 
side  of  the  band  were  attached  hooks  for  ligatures,  which  extended 
back  and  were  tied  to  the  bicuspids.  Delabarre  used  a  gold  cap 
with  a  ligature  for  this  purpose;  and  in  dental  literature  there  are 


COLLARS  107 

many  doscriptions  of  collars  \vitli  knobs,  hooks,  eyelets,  bars,  spurs, 
or  tubes  attached  for  supporting  apparatus. 

Dr.  Thomas  W.  Evans,  when  he  returned  from  Paris  in  1853,  on 
a  visit  to  this  country,*  described  a  means  of  anchorage  made  by 
soldering  a  metal  tube  to  the  side  of  a  collar,  or  by  soldering  a  tube 
to  the  side  of  a  yoke  or  skeleton  cap,  consisting  of  two  nicely  adjusted 
bands  or  rings  that  had  been  properly  fitted  to  the  teeth.  Through 
the  tubes,  in  some  instances,  he  passed  a  hard-drawn  wire,  and  to 
others  were  attached  a  rigid  bar  with  screw  and  nut,  or  an  elastic 
bar,  to  be  "  lengthened  or  shortened  with  screw-nuts."  Since  that 
time  the  tube  soldered  to  a  collar  has  been  in  general  use  for  different 
purposes  in  regulating. 

In  1871  Dr.  W.  E.  Magill  drew  the  attention  of  the  profession  to 
his  method  of  attaching  collars  firmly  to  the  teeth  by  cementing 
them  with  oxychloride  of  zinc.  Later  oxyphosphate  cement  was 
used. 

This  process  of  attaching  collars  to  the  te'^th  made  it  possible  to 
do  away  with  many  of  the  cumbersome  appliances  that  had  been 
employed,  and  lessened  the  injury  to  tooth-structure  and  the  gum 
that  had  been  caused  by  the  ligature  and  other  insecure  apparatus. 

As  a  general  means  of  anchorage,  the  use  of  collars  on  individual 
teeth  seems  objectionable,  as  it  is  usually  necessary  to  separate  the 
teeth  by  wedging  for  their  adjustment,  and  when  several  collars 
are  used  together  at  the  same  time  for  anchorage,  a  considerable 
space  is  necessarily  taken  up  by  the  combined  thickness  and  con- 
tour of  the  metal,  and  this  very  often  when  it  is  desirable  to  lessen, 
rather  than  to  increase,  the  circle  of  the  arch.  Again,  the  crowns 
of  the  teeth  are  larger  near  their  grinding  surface,  making  it  quite 
impossible  to  contour  the  collars  to  fit  closely  the  neck  of  the  tooth 
when  adjusted.     This  causes  difficulty  in  properly  cementing  them. 

Making  Collars. — A  collar  adapted  for  anchorage  is  made  of  a 
strip  of  plate-metal  about  three-sixteenths  of  an  inch  wide,  and 
about  36  gauge,  or  thinner,  according  to  the  stiffness  of  the  metal. 
The  metals  most  employed  are  gold-faced  platinum,  platinized  gold, 
platino-iridium,  gold,  platinoid,  and  German  silver.  The  two  latter 
metals  oxidize.  This  can  be  prevented  in  a  measure  by  gilding 
or  gold-plating  them. 

*  Evans,  Dental  News  Letter,  1853,  p.  70. 


108  ANCHORAGE  AND  APPLIANCES 

Tlie  collar  can  be  formed  on  a  model,  but  the  result  is  generally 
more  satisfactory  when  it  is  shaped  to  the  natural  tooth.  If  the 
metal  does  not  pass  freely  between  the  teeth,  they  may  be  wedged 
slightly.  When  much  strain  is  to  be  put  on  it,  the  collar  should  be 
rather  broad.  It  is  gen-erally  formed  with  the  ends  lapping  on  the 
lingual  side,  crossing  at  an  angle  best  suited  to  make  a  good  adapta- 
tion to  the  tooth,  and  should  be  well  fitted,  but  not  so  closely  as  to 
prevent  its  easy  removal  and  replacement  for  cementing.  For  incisors 
or  cuspids,  the  collar  can  be  made  in  the  usual  manner,  with  the 
ends  lapping  by  one  another,  and  the  points  that  project  tow-ards  the 
gum  on  the  palatal  side  trinmied  off;  or  the  metal  can  be  stretched 
on  one  side,  or  cut  into  a  curved  strip,  Avhich  will  permit  the  ends  to 
lap  in  good  form.  A  method  that  leaves  the  lap  of  the  collar  smooth 
when  finished,  but  narrower,  is  to  cut  a  small  V-shaped  piece  out  of 
either  end,  adjusting  it  to  the  tooth,  with  the  ends  drawn  together  on 
the  lingual  surface  and  soldered. 

When  there  is  to  be  a  projection  from  the  collar  on  the  distal  or 
the  mesial  surface  for  the  purpose  of  retaining  a  tooth  that  has  been 
rotated,  or  to  hold  an  appliance  from  slipping  from  the  lingual  sur- 
face of  the  incisors,  it  can  easily  be  made  in  conjunction  with  the 
collar,  by  passing  a  strip  of  metal  around  the  tooth,  pressing  the  ends 
together,  and  soldering  them,  leaving  them  projecting  at  a  right  angle, 
forming  a  spur  (Fig.  75).*  The  projecting  ends  can  be  ground  or 
P  ^.  filed  to  any  desired  shape  to  serve  as  a  lug.  A  spur  of 
metal  or  a  tube  may  be  soldered  to  the  collar  for  this 
purpose.  Gold  solder  is  applied  to  the  joint  and  made 
to  flow',  by  holding  the  parts  in  a  flame  with  a  small  pair  of  pliers, 
using  dry  or  moist  pulverized  borax  as  a  flux. 

Many  varieties  of  pliers  are  offered  by  dealers  for  the  purpose  of 
supporting  collars  in  soldering,  and  tubes  and  lugs  in  position  on  the 
collars  while  uniting  them.  The  points  of  the  pliers  should  be  small, 
less  heat  being  thus  required. 

In  cernenthif/  the  collar  to  the  tooth,  the  inner  surface  should  first 
be  roughened  or  slipjjled  by  raising  ridges  wdth  a  sharp  instrument, 
and  the  tooth  ijolisluMl  with  a  fine  grade  of  pumice,  wdiich  will  cause 
the  cement  to  adhere  more  firmly  to  them.  The  cement  should  not 
be  loo  thin  ;    keep  it  free  from  moisture   by  the   use  of  a  rubber 

*J;icksoii,  Inleriialioriul  Deiiliil  JnuriKil,  1890,  p.  200. 


TUBES  AND  LUGS  109 

dam,  or  napkins  and  spunk.  In  adjusting  tlie  collar,  care  should  be 
exercised  that  the  cement  be  so  distributed  as  to  till  all  of  the  space 
underneath  it.  This  will  both  insure  strength  to  the  attachment 
and  protect  the  surface  of  the  tooth  from  the  secretions.  The  collar 
is  most  easily  cemented  by  holding  the  point  of  the  finger  or  a  small 
piece  of  oiled  paper  over  its  lower  opening,  and  placing  the  cement 
in  it.  The  collar  is  then  forced  on  tlie  tooth,  with  the  end  covered 
in  this  manner,  which  presses  tlie  cement  around  the  tootli  in  ad- 
vance of  the  collar  filling  all  of  the  undercuts. 

Collars  set  with  oxyphosphate  cement  for  regulating  purposes 
should  be  examined  at  least  once  in  three  months,  passing  an  instru- 
ment along  the  edges  to  determine  if  the  cement  has  become  affected, 
as  it  is  liable  to  waste  away,  and  the  surface  of  the  tooth  to  be  acted 
upon  by  the  fluids  of  the  mouth. 

Wlien  it  is  found  necessary  to  readjust  a  collar,  it  can  generally  be 
removed  without  cutting,  by  using  a  pointed  instrument,  similar  in 
shape  to  a  spatula,  thin  at  the  edges,  and  sufficiently  thick  in  the  centre 
to  give  it  rigidity.  The  point  of  the  instrument  should  be  pressed 
underneath  the  edge  of  the  collar  and  worked  sideways  back  and 
forth,  gradually  stretching  the  metal  and  forcing  the  cement  before  it. 

The  spur,  tube,  and  plain  lug  are  tlie  attachments  to  the  collar 
most  generally  described  in  this  book,  although  other  forms  are 
used  and  will  be  referred  to  in  the  description  of  special  cases. 

Tubes. — Tubes  of  any  metal,  thickness,  or  diameter  suitable  for 
the  purpose  of  regulating  can  be  procured  in  c|uantity  of  the  dealer. 
The  tube  can  be  made  by  drawing  a  narrow  strip  of  thin  metal  with 
a  draw-plate,  or  by  wrapping  a  thin  piece  of  sheet  metal  around  a 
wire  with  flat-nosed  pliers  and  rolling  it  between  two  smooth  pieces 
of  wood  or  metal.  The  tube  is  then  soldered  to  the  collar,  with 
the  joint  placed  towards  the  collar,  so  that  it  will  be  united  at  the 
same  time  it  is  being  joined  (Fig.  76).  To  prevent  the  solder  running 
into  the  tube,  it  is  sometimes  an  advantage  to  paint  the 
inside  with  whiting,  close  the  tube  with  mouldine,  or  pass 
into  the  opening  a  lead  like  those  used  in  adjustable  pencils. 

Lugs. — A  lug  is  a  small  piece  of  metal  projecting  from 
a  collar,  for  retaining  the  end  of  a  spring  or  other  portion  of  a 
regulating  appliance.     It  is   united    to    the    collar,   usually  on    the 
lingual  side  near  the  guin.     A  lug  made  of  a  piece  of  plate-metal 
is  generally  employed  (Fig.  77). 


110  ANCHORAGE  AND   APPLIANCES 

The  metal  is  bent  at  a  right  angle  or  an  acute  angle,  is  as  long 
as  the  width  of  the  tooth,  and  broad  enough  to  retain  the  appliance. 
Before  being  soldered  to  the  collar,  it  should  be  so  bent  that 
when  the  collar  is  adjusted  it  will  rest  at  a  right  angle  with  the 
long  axis  of  the  tooth,  or  curved  somewhat  towards  the  neck,  and 
not  at  an  obtuse  angle,  as  with  the  latter  shape  the  tooth  would 
be  likely  to  gradually  move  forward  and  disengage  the  lug.  A 
lug  made  of  plate-metal  in  this  manner  gives  a  broad  surface  for  the 
application  of  force,  the  tooth  being  less  liable  to  become  rotated 
during  its  movement  than  with  a  lug  of  other  form.  The  broad  lug 
is  an  advantage  when  the  tooth  is  twisted,  the  application  of  properly 
directed  force  tending  to  correct  its  position.  A  wire,  round  or 
square,  a  tube  (Fig.  78),  or  a  cylinder  with  a  section  removed  (Fig. 
79)  can  be  employed. 

The  metals  used  may  be  either  gold,  gold-faced  platinum,  platino- 
iridium,  platinoid,  or  German  silver,  any  of  which  can  be  united 
with  18-carat  gold,  or  silver  solder.  If  base-metals  are  used,  care 
should  be  exercised  not  to  overheat  when  soldering. 

Soldering-. — It  is  important  that  the  spring  temper  of  the  metals 
used  in  making  appliances  should  not  be  interfered  with  by  over- 
heating in  the  process  of  uniting  them.  For  this  reason,  a  solder 
that  fuses  at  a  low  temperature  should  be  employed  when  prac- 
ticable. 

Any  of  the  metals  used  for  springs  can  be  soldered  with  soft 
solder  or  pure  tin  without  injuring  the  elasticity  when  done  carefully 
with  the  soldering  iron.  Three  grades  of  soft  solder  are  generally 
quoted, — fme  solder,  2  parts  of  tin  to  1  of  lead  ;  common  solder, 
1  part  tin  to  1  of  lead;  cheap  solder,  1  part  tin  to  2  of  lead. 
Jeweller's,  or  fme  soft  solder,  is  generally  used  for  uniting  platinoid 
or  German  silver  appliances.  Chemically  pure  tin  requires  a  higher 
temperature  and  more  care  in  soldering,  but  is  considered  less 
liable  to  oxidize. 

The  essentials  in  soft  soldering  are — 

Clean  and  hri(jht  metals. 

A  Hoft  solder  of  good  quality. 

A  jiux,  chloride  of  zinc  (sometimes  called  muriate  of  zinc),  pre- 
pared by  dissolving  crystals  of  chloride  of  zinc  in  a  small  portion 
of  water.  (The  crystals  have  an  affinity  for  water,  and  when 
left  exposed    to    the   atmosphere    they  soon    absorb  moisture  and 


Fig.  77. 


Fig.  78. 


Fig.  79. 


Fig.  80. 


SOLDERING  111 

liquefy).  Muriate  of  zinc  is  prepared  by  dissolving  granules  of  pure 
zinc  in  hydrochloric  acid,  usually  fornung  a  saturated  solution. 
VVlien  dissolved,  and  all  effervescence  has  ceased,  allow  it  to  settle, 
then  decant  the  clear  solution  from  the  sediment,  and  it  is  ready  for 
use.  If  a  small  quantity  of  water  is  added  to  the  mixture  at  this 
stage,  say  one-sixth,  it  will  answer  quite  as  well.  For  soldering 
steel,  a  very  small  portion  of  sal  ammoniac  added  to  the  mixture  is 
of  advantage  for  giving  toughness. 

A  soldering  iron,  about  three-fourths  of  an  inch  square,  by  three 
inches  long,  made  of  pure  copper  with  the  point  well  tinned. 

A  Bunsen  or  clectrio  heater  of  almost  any  form  for  heating  the 
soldering  iron. 

The  soldering  can  be  done  most  easily  when  the  iron  is  kept 
bright  and  in  good  condition.  It  should  be  very  hot,  but  if  over- 
heated, it  burns  the  tinning  and  the  copper,  and  a  greenish  flame 
will  be  observed.  To  prevent  the  burning,  the  heat  should  not  be 
excessive,  and  should  usually  be  applied  at  the  centre  of  the  iron. 
A  stronger  attachment  is  made  when  the  surfaces  of  the  metals  used 
are  first  tinned  by  rubbing  them  with  the  soldering  iron. 

In  soldering,  the  partial-clasps,  spring-clasps,  base-wire,  and  spring 
should  be  placed  in  position  on  the  model  (see  Figs.  53,  56,  57). 
The  point  of  a  pin  is  pressed  into  the  plaster  on  the  buccal  surface 
of  the  teeth  above  each  of  the  spring-clasps  to  prevent  them  from 
raising  out  of  position  while  soldering  (Fig.  80).  The  base-wire  and 
other  parts  can  be  held  in  position  with  moulcline,  as  seen  in  the 
figure  ;  or  with  a  wad  of  cotton  or  paper  held  by  the  hand.  AVhen 
the  iron  is  hot,  pieces  of  solder  sufficiently  large  are  laid  in  contact 
with  the  metal,  and  the  parts  fluxed  by  touching  them  with  chloride 
of  zinc.  The  soldering  iron  is  then  passed  over  the  solder,  which 
flows,  uniting  all  of  the  parts  at  once,  and,  if  only  sufficient  solder  is 
used,  no  dressing  or  polishing  will  be  required. 

Attachvient  of  Springs  with  Solder. — A  spring  for  moving  the  teeth 
can  be  attached  with  solder  to  the  partial-clasp  of  an  appliance  at 
the  time  the  spring-clasp  and  base-wire  are  united.  Or  the  spring 
can  be  attached  to  any  part  of  the  base-wire  with  soft  solder,  by 
passing  underneath  the  base-wire  and  spring,  when  on  the  model,  a 
curved  piece  of  partial-clasp  metal,  as  wide  as  it  is  intended  to  have 
the  soldered  portion  when  finished ;  then  solder  witli  the  soldering 
iron.     A  spring  or  hook  can  be  attached  to  the  spring-clasp  in  a 


112  ANCHORAGE   AND  APPLIANCES 

similar  manner.  A  method  of  attaching  springs  that  is  considered 
stronger  is  to  wind  around  the  base-wire  and  the  end  of  the  spring 
to  be  joined  a  narrow  strip  of  thin  metal,  as  tinned  platinoid  or 
German  silver,  which  have  an  affinity  for  the  solder,  and  the  solder- 
ing done  with  the  soldering  iron  as  before  (Fig.  81). 

Fig.  si. 


Fig.  82. 


LiMiiiiiiiiiiiiiiiuitiiiiiiiiiiiiiiiiiiiuiwi-^ 


-WnllllllMm 


If  a  piano-wire  spring  is  to  be  employed,  copper  binding-wire 
wound  about  the  springs  for  joining  the  wires,  as  seen  in  Fig.  82,  has 
proved  satisfactory. 

Finishing  and  polishing  an  Appliance. — Any  excess  ot  metal  or 
solder  can  be  removed  with  a  file,  scraper,  or  coarse  corundum  stone, 
and  the  parts  polished  with  any  plate-polishing  powder,  or  they  can 
be  burnished. 

Gold  and  Silver  Solder. — When  any  appliance  is  to  be  made  of 
precious  metals,  gold  solder  should  be  employed.  A  solder  of  18-, 
14-,  or  a  lower  carat  is  applicable,  according  to  the  spring  metals 
used.  Appliances  of  platinoid  or  German  silver  can  also  be  united 
with  gold  or  silver  solder.  The  model  should  be  made  of  plaster 
or  marble-dust,  or  their  equivalents,  and  the  apparatus  soldered  on 
the  model ;  or  the  parts  should  be  held  in  position  on  a  plaster 
model  and  united  with  hard  wax,  after  which  they  can  be  removed 
together  and  invested  sufficiently  with  plaster  and  marble-dust  to 
hold  them  in  position  while  soldering.  Use  moistened  borax  as  a 
flux,  and  proceed  in  the  same  manner  as  for  attaching  a  clasp  to  a 
gold  plate. 

The  springs  should  not  be  overheated,  as  this  generally  im])airs 
their  elasticity.  The  parts  can  be  carefully  burnished,  liowever, 
which  will  to  some  extent  restore  the  springiness  of  the  metal. 

Repairing  Appliances.— Tlie  imperfect  fit  of  an  appliance  may 
result  from  being  maih;  on  an  imi)erfect  model,  or  from  the  careless 
adjustment  of  the  partial-clasps  or  spring-clasps.     In  remaking  or 


REPAIRING  APPLIANCES  113 

repairing,  when  soft  solder  is  used,  unsolder  the  parts  with  a  gentle 
heat,  shake  off  the  excess  of  solder,  and  readjust  and  solder  them 
on  an  accurate  model. 

If  the  apparatus  becomes  broken  or  unsoldered,  it  can  be  re- 
soldered  on  the  model,  or  new  parts  can  be  formed  and  added  to 
the  appliance  in  the  manner  described.  Sometimes  a  spring  can 
be  added  or  other  repairing  done  by  supporting  tlie  parts  of  the 
appliance  with  mouldine  or  plaster  of  Paris  for  soldering.  If  a 
spring  is  to  be  attached  to  a  soldered  portion,  a  groove  can  be  cut 
for  it  in  the  solder. 

A[)i)liances  of  gold  are  repaired  in  the  same  manner  as  in  making. 

Action  of  Spring. — Usually,  when  a  new  appliance  is  inserted  in 
the  mouth,  it  should  not  be  removed  for  three  days,  that  the  patient 
may  become  accustomed  to  it  before  applying  force.  After  that  time 
the  pressure  may  be  changed  slightly  about  once  a  week,  or  oftener 
if  desired.  Of  course,  much  depends  upon  the  character  of  the 
case.  To  save  time  and  repetition,  it  will  be  explained  here  how 
the  force  of  the  spring  is  to  be  modified. 

Pressure  is  increased  by  removing  the  appliance  and  bending  the 
spring  in  the  direction  in  which  the  force  is  desired.  Thus,  where  a 
tooth  is  inside  the  normal  line,  the  pressure  of  the  spring  is  out- 
ward, and  any  increase  of  force  is  obtained  by  bending  the  spring 
accordingly.  On  the  other  hand,  when  a  tooth  is  to  be  moved 
inward,  the  spring  extended  to  rest  on  the  outer  surface  is  curved 
inward.  When  discomfort  is  caused  by  excessive  force,  it  can 
generally  be  relieved  by  holding  hot  water  in  the  mouth. 

A  system  of  graduated  measurement  of  the  changes  of  the  springs 
should  be  adopted  to  insure  a  steady  progressive  movement.  This 
can  be  done  by  placing  the  appliance  on  a  card  and  marking  its 
outlines  with  a  sharp-pointed  pencil,  affixing  the  date ;  keeping  the 
card  as  a  permanent  record.  Each  time  that  additional  force  is  to  be 
applied  a  new  indication  should  be  made  with  pencil  on  the  card, 
noting  the  date  and  the  distance  it  is  desired  to  bend  the  spring. 
The  spring  is  then  bent  slightly  and  verified  until  it  conforms  to  the 
new  marking.  Comparison  of  the  appliance  with  the  markings  on  the 
card  is  made  easier  by  always  placing  the  appliance  and  card  against 
a  slight  ledge  when  marking  the  outlines  and  changes. 

These  principles,  involving  systematic  changes  of  force  with  the 
spring,  apply  to  all  the  modifications  of  my  appliances. 

8 


114  ANCHORAGE  AND  APPLIA>XES 

Resume. — In  completing  the  chapter  on  means  of  anchorage  and 
making  appliances,  I  would  recapitulate  the  advantages  of  my  system. 

First.  The  simplicity  and  ease  of  construction  of  the  apparatus. 

Second.  It  is  equally  applicable  for  the  regulation  of  the  teeth  of 
the  child  or  the  adult. 

Third.  It  is  suitable  for  all  forms  of  irregularity,  doing  away  with 
the  use  of  a  plate  in  a  large  majority  of  cases. 

Fourth.  It  is  well  retained  in  apposition  with  the  teeth,  and  when 
the  appliance  is  properly  made  it  causes  no  inconvenience.  It  does 
not  interfere  materially  with  speech  or  with  the  occlusion  of  the 
teeth,  even  when  an  apparatus  is  used  in  both  the  upper  and  the 
lower  arch  at  the  same  time. 

Fifth.  While  the  anchorage  is  sufficiently  firm  for  all  practicable 
purposes,  the  appliance  can  usually  be  removed  by  the  patient,  thus 
favoring  cleanliness. 

Sixth.  It  can  be  so  arranged  that  some  of  the  teeth  to  be  moved 
later  in  the  process  of  regulating  can  be  employed  to  assist  the 
anchorage,  thereby  lessening  the  disturbance  of  the  anchorage-teeth 
when  extreme  force  is  applied. 

Seventh.  The  force  caused  by  the  appliance  for  moving  the  teeth 
is  well  under  control,  and  requires  less  attention  than  with  the 
apparatus  generally  used,  thus  saving  the  time  both  of  the  patient 
and  the  operator. 

Eighth.  Tlie  appliance  can  be  made  of  almost  any  of  the  pre- 
cious metals  that  are  springy  or  of  base  metals.  Those  most  usually 
employed  are  spring-gold,  platinoid,  German  silver,  wire,  and  plate. 
They  are  easily  manipulated,  and  the  two  latter  are  inexpensive  and 
easily  obtained. 

Ninth.  The  spring-clasp  attachment,  base-wire  and  spring-wire 
construction  are  simple  and  quickly  prepared.  Changes  and  additions 
to  the  apparatus  are  readily  made. 

Tenth.  A  part  or  the  whole  of  an  appliance  can  be  made  of  the 
precious  metals,  when  desired. 

Eleventh.  Gold  or  silver  solder  may  be  used  for  uniting  the  appli- 
ance, or  the  soldering  simplified  by  the  use  of  jeweller's  soft  solder. 
The  latter  interferes  less  with  the  spring  properties  of  the  metals, 
and  changes  in  the  apparatus  by  soldering  and  unsoldering  are  easily 
made. 

Twelfth.  Many  of  the  springs  described  can  be  used  to  advantage 


RESUME— EARLIER  METHODS  Ho 

in  combination  witli  other  means  of  anchorage,  especially  with  a 
rubber  or  metal  plate.  The  construction  of  the  apparatus  is  suitable 
for  the  apiilieation  of  supplemental  force,  either  with  a  cross-bar,  a 
chin-cap,  a  supralabial,  or  an  infralabial  bar. 

Thirteenth.  Almost  any  of  the  appliances  can  be  continued  in  use 
tor  retaining  the  teeth  in  position  after  completing  their  regulation. 

Fourteenth.  The  models  of  each  case  are  usually  uninjured  in 
making  tlie  appliance,  and  can  be  preserved  for  future  reference  and 
study. 

Fifteenth.  For  record  the  models  are  mounted  on  boards,  the 
models  of  the  upper  and  lower  arch  being  articulated.  One  series 
of  models  will  thus  show  the  position  of  the  teetli  before  regulating, 
the  progressive  changes  under  treatment,  the  apparatus  used,  and, 
finally,  the  result  of  the  successful  treatment. 

Early  Methods. — Among  the  earlier  methods  of  regulating  are 
descriJjed  the  mani|)ulation  of  the  teeth  with  the  fingers  (see  page 
210),  the  movement  of  the  teeth  with  cord  ligatures,  with  long  metal 
bands,  inclined  planes,  etc. 

Ligature. — The  ligature  was  employed  for  moving  irregular  teeth 
by  weaving  it  among  them,  so  that  it  would  pass  in  front  of  the 
prominent  ones  and  back  of  those  to  be  made  more  prominent. 
The  ligature  was  then  stretched,  and  the  ends  securely  tied  for 
anchorage  to  one  or  more  of  the  teeth  not  to  be  moved. 

Long  Band  and  hicUned  Plane. — Appliances,  including  the  long 
band  and  metal  inclined  plane,*  were  tied  with  ligatures  to  suitable 
teeth  for  anchorage.  An  objectionable  feature  of  this  form  of 
anchorage  was  the  slipping  of  the  ligature  on  the  teeth,  permitting 
movement  of  tlie  apparatus  and  consequent  injury  to  the  gum.  The 
difficulty  was  finally  overcome  by  making  the  attachment  to  the 
teeth  with  bands,  ferrules,  or  clasps. 

Metal  Plates. — The  metal  plate,  fastened  to  the  teeth  with 
ligatures,  bands,  or  clasps,  has  also  been  in  use  many  years  for 
regulating.!  It  is  sometimes  employed  by  the  writer  as  an  anchor- 
age for  metal  springs  soldered  to  its  surface,  the  plate  being  retained 
with  wire  clasps  or  by  suction. 


*  Fox  and   Harris,  1846,    p.  100;   Catalan,   Journal   General  de  Medecine,  de 
Chirurgie  et  de  Pharniacie,  January,  1814. 

f  Hunter,  Natural  History  of  the  Human  Teeth,  1778,  p.  77. 


116  ANCHORAGE   AND   APPLIANCES 

Ihibbcr  Plates  and  Jnclincd  Fhtucs. — Since  the  introduction  of 
vulcanite  rubber  in  1839  it  has  been  used  extensively  for  inclined 
planes,  plates,  and  anchorage  for  screws,  for  expanding  the  arch  and 
moving  irregular  teeth. 

Later  Methods. — At  the  International  Medical  Congress  in  Lon- 
don, 1881,  W.  H.  Coffin  presented  a  paper  describing  what  he 
termed  the  "  Expansion  Method"  that  had  been  used  in  practice  by 
his  father  and  Dr.  Headridge  for  many  years.  The  method  attracted 
general  attention.  It  consists  of  anchoring  vulcanite  plates  by  ex- 
tending the  rubber  over  the  molars  and  bicuspids.  The  plates  are 
usually  divided  in  the  centre.  In  the  rubber  are  attached  piano-wire 
springs  for  spreading  the  arch  and  moving  the  irregular  teeth.  The 
principle  in  the  construction  of  the  apparatus  is  as  follows :  A 
wax  try-plate  is  fitted  to  an  accurate  model  covering  the  arch,  ex- 
tending over  the  bicuspid  and  molar  teeth  to  the  buccal  side  near  the 
gum.  Springs  of  piano-wire  with  tlie  end  flattened  are  embedded  in 
the  wax  in  the  position  desired,  and  the  part  flasked  in  the  usual 
manner,  the  free  ends  of  the  springs  being  retained  in  the  plaster. 
Piubber  is  then  packed  in  place  of  the  try-plate,  and  the  plate  vul- 
canized and  polished.  The  fitting  of  the  rubber  about  the  teeth 
generally  holds  the  plate  quite  firmly  in  position  when  made  on  an 
accurate  model,  and  but  little  dressing  is  required.  (A  more  detailed 
description  of  the  Coffin  method  will  be  found  in  Chapter  IX.,  Ex- 
pansion of  the  Dental  Arch.) 

Drs.  Farrar,  Patrick,  and  Angle  have  each  recommended  a  method 
of  attaching  apparatus  to  the  crowns  of  teeth  with  open  collars, 
provided  with  bolt  and  nut  for  drawing  the  free  ends  of  the  collars 
together.  To  the  collars,  in  some  instances,  are  soldered  bars,  tubes, 
spurs,  or  eyelets,  to  make  suitable  attachment  for  holding  apparatus, 
screws,  jack-screws,  rubber  bands,  etc.,  for  moving  the  teeth.  Many 
examples  of  these  procedures  are  found  in  their  writings. 


CHAPTER   VIII 

WEDGING— APPLICATION    OF    FORCE— MOVEMENTS   OF   THE    TEETH- 
CARE    OF   THE   TEETH    AND  APPLIANCES    DURING    REGULATION 

Wedging. — The  wedge  is  not  employed,  as  formerly,  as  a  force  for 
the  purpose  of  regulating  teeth,  but  is  now  used  principally  for  sepa- 
rating the  teeth  to  permit  of  the  adjustment  of  aj^paratus.  Imme- 
diate wedging  can  be  accomplished  by  the  use  of  a  metallic  separa- 
tor or  a  properly  shaped  wooden  wedge.  Soft  rubber  is  used  for 
wedging,  but  is  liable  to  cause  excessive  soreness  when  allowed  to 
remain  between  the  teeth  longer  than  from  three  to  four  hours.  It 
is  sometimes  applied  longer  to  cause  congestion  for  assisting  an  appa- 
ratus to  start  the  teeth  in  their  movement. 

When  active  congestion  is  not  desired,  sterilized  cotton  or  tape  for 
wedging  is  more  acceptable.  It  can  be  introduced  and  held  in  posi- 
tion by  first  passing  between  the  teeth  two  cords  of  waxed  saddler's 
silk  twist,  or  linen  doubled  upon  itself,  and  left  sufficiently  long  to  tie 
well.  One  or  more  thicknesses  of  sterilized  cotton  tape  well  waxed 
are  then  drawn  between  the  teeth  and  kept  dry.  The  ends  of  the 
tape  are  clipped  off  close  to  the  teeth,  the  twist  drawn  around  the 
remaining  part,  packing  it  firmly  between  the  teeth,  drawn  as  tight  as 
desired,  and  well  tied  with  a  square  knot. 

The  ends  of  the  cord  are  then  removed  with  scissors  and  the  knot 
rubbed  down.  If  there  are  cavities,  sterilized  cotton  pressed  into> 
place  will  often  be  more  serviceable.  This  means  of  wedging  is  ap- 
plicable for  the  molars  or  bicuspids  as  well  as  the  incisors.  A  wedge- 
inserted  in  this  manner  is  acceptable  to  the  patient,  is  not  easily  dis- 
placed, acts  rapidly,  causes  little  or  no  soreness,  and  is  comfortably 
and  easily  applied.  The  twist  used  for  wedging  can  be  prevented 
from  unwinding  from  the  spool  by  passing  the  end  through  the  hole 
in  the  centre  and  cutting  a  notch  in  the  edge  corresponding  with  the 
angle  the  cord  takes  when  it  passes  over  before  entering  the  hole. 
After  unwinding  the  desired  amount,  the  spool  is  allowed  to  drop,  the 
twist  thus  catching  in  the  notch  and  preventing  further  unwinding. 

The  Application  of  Force. — It  is  not  my  intention  here  to  dis- 
cuss its  principles,  but  to  speak  more  especially  of  its   means  of 

117 


118  WEDGING— APPLICATION   OF   FORCE 

application  as  pertaining  to  orthodontia.  There  has  been  a  di- 
versity of  opinion  among  writers  witliin  the  last  few  years  regard- 
ing the  better  means  of  applying  force  to  cause  the  movement  of 
irregular  teeth,  and  especially  whether  the  force  shall  be  constant  or 
intermittent.  Some  favor  the  action  of  a  spring  or  constant  press- 
ure, and  others  the  action  of  a  screw  or  intermittent  pressure ;  but 
all  agree  that  in  general,  whether  the  force  be  constant  or  intermit- 
tent, it  should  be  applied  as  near  as  possible  at  a  right  angle  to  the 
long  axis  of  the  tooth. 

Dr.  Farrar,  in  a  series  of  papers  in  the  Dental  Cosmos  (1876-78), 
and  in  his  work  on  Irregularities,  vol.  i.  p.  159,  has  given  preference 
to  the  screw  or  intermittent  pressure  for  regulating  purposes.  Its 
application  he  terms  the  "positive  system,"  and  enlarges  on  inter- 
mittent force  as  analogous  to  the  law  of  "  Labor  and  Rest."  In  con- 
sidering this  view  from  a  physiological  stand-point,  in  discussion,  I 
made  the  following  statement,*  which  has  been  verified  in  my  prac- 
tice :  "  The  law  of  nature  is,  that  alternating  pressure  and  relief  cause 
hypertrophy,  increased  growth,  and  hardening,  while  constant  press- 
ure causes  atrophy  or  absorj^tion.  If  you  want  absorption,  you 
must  keep  up  a  constant  pressure  without  intermission  or  rest.  We 
want  absorption  of  the  alveolar  process  in  cases  of  regulating." 

The  tissues  involved  in  regulating  are  tolerant  of  any  kind  of  direct 
moderate  force,  whether  constant  or  intermittent,  excepting  a  force 
that  is  vacillating, — that  is,  not  having  a  definite  fixed  point  of  resist- 
ance and  action, — as  is  common  in  insecurely  anchored  regulating 
appliances,  wedging  of  the  teeth  with  rubber,  etc.,  which  produce  an 
objectionable  inflammation.  The  force  for  moving  the  teeth  should 
be  applied  in  such  a  manner  that  the  device  will  not  impinge  too 
heavily  on  the  soft  tissues,  in  my  experience,  the  force  of  a  spring 
generated  with  slight  variations  is  more  effective,  more  agreeable  to 
the  patient,  and  requires  less  attention  than  other  means. 

Movements  of  the  Teeth. — Terms  to  describe  the  movements  of 
the  teeth  slumld  be  few  and  concise.  A  chart  (Fig.  83)  has  been 
prepared  to  indicate,  some  of  their  more  common  movements  during 
regulating. 

A,  incisors,  to  move  outward,  or  labially ;  B,  incisors,  to  move 
inward,  or  lingually ;    C,  incisors,  to  move   laterally ;    A',  cuspids, 


*  Jiuksoii,  Denial  Cosmos,  18«7,  p.  385. 


MOVEMENTS   OF  THE   TEETH 


119 


bicuspids,  and  molars,  to  move  outward,  or  in  a  buccal  direction ; 
B',  cuspids,  l)ieuspids,  and  molars,  to  move  inward,  or  in  a  lingual 
direction  ;  D,  cuspids,  bicuspids,  and  molars,  to  move  forward  in  the 
line  of  the  arch  ;  E,  cuspids,  bicuspids,  and  molars,  to  move  back- 
ward in  the  line  of  the  arch  ;  F,  rotation  of  the  teeth  ;  G,  depression 
of  teeth  in  their  alveoli ;  H,  elevation  of  teeth  in  their  alveoli. 

Care  of  Teeth  and  Appliances  during  Regulation. — Thorough 
cleansing  of  the  mouth  and  teeth  is  necessary  at  every  time  of  life. 
Friction  witli  a  good  powder  and  brush  is  the  first  essential.     The 


A,  incisors  to  move  outward. 

B,  incisors,  to  move  inward. 

C,  incisors,  to  move  laterally. 

A',  cuspids,  bicuspids,  and  molars,  outward 
B',  cuspids,  bicuspids,  and  molars,  inward. 


Movements  of  the  Teeth. 

D,  cuspids,  bicuspids,  and  molars,  forward. 


E,  cuspids,  bicuspids,  and  molars,  backward. 

F,  rotation  of  the  teeth. 

G,  depression  of  the  teeth. 
H,  elevation  of  the  teeth. 


brush  should  have  sufficient  bristles,  and  sliould  not  be  too  stiff,  as 
some  of  the  bristles  have  to  bend  to  permit  others  to  reach  between 
the  teeth  ;  nor  should  the  bristles  be  too  soft,  as  consideralDle  stiff- 
ness is  required  to  cause  the  necessary  friction  for  removing  tartar 
and  other  collections.  These  are  irritants  to  the  gum,  and  cause  it  to 
become  congested  and  bleed  easily.  Benefit  to  the  gum  is  derived 
from  massage  and  friction  if  not  too  severe.  Generally  when  the  gums 
bleed  the  brushing  should  be  more  vigorous.     In  passing  the  brush 


120  WEDGING— APPLICATION   OF  FORCE 

across  the  teeth,  the  bristles  jump  from  one  tooth  to  another  and  do 
not  reach  between  them  as  they  should,  but  in  making  the  motion 
downward  from  the  gum,  or  up  and  down,  the  bristles  pass  between 
the  teeth,  causing  the  desired  friction  on  their  approximal  surfaces. 

A  suitable  mouth-wash  is  useful  as  a  disinfectant,  but  care  should 
be  exercised  in  its  choice.  A  solution  that  will  remove  calcareous 
deposits  from  the  teeth  will  usually  affect  the  tooth-structure. 

Fixed  regulating  appliances  should  be  cleansed  thoroughly  with 
the  teeth.  Removable  appliances  should  be  taken  from  the  mouth 
and  the  teeth  and  appliance  cleansed  at  least  twice  a  day,  in  the 
morning  and  at  night.  If  neglected,  the  metal  is  liable  to  become 
tarnished  and  stain  the  teeth.  Thorough  brusliing  with  a  tooth- 
powder  and  brush  is  generally  sufficient  for  cleansing  appliances,  but 
sometimes,  owing  usually  to  the  condition  of  the  secretions,  a  tarnish 
is  formed  on  the  metal  which  requires  a  more  active  powder,  as 
powdered  pumice.  Some  of  the  metal-polishing  preparations  on 
the  market  are  even  more  efficacious.  When  the  tarnish  is  not 
removed  easily,  first  place  the  appliance  for  a  few  moments  in 
alcohol  or  a  weak  alkaline  solution ;  it  is  then  readily  brightened  by 
brushing  it  with  powder. 

The  deciduous,  as  well  as  the  permanent  teeth,  should  be  pre- 
served by  thorough  filling. 


CHAPTER  IX 

EXPANSIUX  OF  THE  DENTAL  ARCH 

Where  the  teeth  are  irregular,  they  are  usually  much  crowded  in 
the  arch,  but  cases  of  irregularity  with  spaces  between  the  teeth 
occur. 

When  the  teeth  are  crowded,  and  some  of  them  irregular,  the 
dental  arch  is  enlarged  by  forcing  the  irregular  teeth  into  proper  line, 
but  the  correction  is  generally  facilitated  by  first  expanding  the  arch. 

Before  increasing  the  circle  of  the  arch  in  any  case,  it  is  necessary 
to  study  the  family  type  and  the  features  of  the  patient,  and  espe- 
cially the  occlusion  of  the  teeth,  in  order  to  determine  whether 
expansion  will  improve  the  contour  of  the  features  and  the  occlusion. 

When  there  is  not  sufficient  breadth  of  the  arch,  the  incisors 
are  usually  too  prominent,  and  need  to  be  moved  inward  to  line. 
To  accomplish  this  without  extraction,  the  sides  of  the  arcli  should 
be  moved  laterally  outward.  This  is  necessary  also  when  the  in- 
cisors are  rotated  on  their  axes  or  overlap  one  another,  but  one 
arch  should  not  be  expanded  to  the  detriment  of  the  occlusion  of 
the  teeth  with  those  of  the  opposite  arch. 

Much  has  been  written  upon  expanding  the  arch  to  improve  the 
occlusion  and  make  room  for  irregular  incisors.  So  many  mistakes 
however,  are  made  in  expanding  the  arch  laterally  by  moving  out- 
ward the  bicuspids  and  molars  without  moving  the  cuspids,  with  a 
view  to  increase  the  space  for  the  incisors,  that  Fig.  84  has  been 
prepared  to  illustrate  the  lines  of  movement  of  these  teeth.  It 
shows  that  the  movement  of  the  molars  and  bicuspids  in  a  buccal 
direction,  as  illustrated  by  the  lines  c,  c/,  e^  and/,  does  not  increase 
the  size  of  the  arch  anterior  to  them,  except  by  a  slight  dragging 
outward  of  the  cuspids,  permitted  by  the  elasticity  of  the  bony  pro- 
cess, which  movement  of  the  cuspids  in  most  cases  is  not  appreciable. 
Therefore  if  more  space  is  needed  for  correcting  the  position  of  the 
incisors,  the  cuspids  should  be  moved  outward  with  the  bicuspids 
and  molars.  When  more  space  is  required  for  the  accommodation 
of  prominent  cuspids,  the  movement  outward  of  the  bicuspids  and 
molars  would  not  improve  the  condition,  as  sufficient  room  for  the 

121 


122 


EXPANSION  OF  THE  DENTAL  ARCH 


cuspids  would  not  be  gained  witliout  excessive  expansion,  interfering 
with  the  occlusion.  If  only  slight  additional  room  is  required  for 
the  incisors,  it  can  in  some  instances  be  gained  by  moving  the  cuspids 
outward  without  interfering  with  the  bicuspids  and  molars,  or  by 


Fig.  84. 


removing  a  little  from  tlie  mesial  and  distal  surfaces  of  the  cuspids 
and  bicuspids  with  a  fine  file,  a  polishing  strip,  or  a  diamond  disk.  In 
some  cases  it  may  be  found  practicable  and  excusable  to  polish  the 
lateral  surfaces  of  the  incisors  in  the  same  manner  rather  than  to 
extract  a  tooth  to  make  the  necessary  room,  but  they  should  not  be 
dressed  to  the  extent  of  removing  all  of  the  enamel  from  any  part. 
In  normal  occlusion  the  teeth  of  the  upper  arch  rest  in  contact 
with  those  of  the  lower,  and,  although  many  changes  take  place  in 
the  order  of  development  of  the  deciduous  and  permanent  teeth,  a 
proper  occlusion  should  be  maintained.  It  is  seldom  expedient  to 
expand  the  upper  arch  to  make  room  for  irregular  teeth  without  a 
corresponding  expansion  of  the  lower  arch,  as  without  the  support 
of  and  correct  occlusion  with  the  latter  the  upper  arch  will  usually 
contract  again  and  the  teeth  rciuni  to  an  irregular  position.  There 
should  also  be  maintained  the  normal  pressure  of  the  tongue  against 
the  teeth  of  each  arch,  which  is  possible  only  in  cases  of  nasal 
breathing.  On  the  other  hand,  tlie  very  gradual  expansion  of  the 
lower  arch  will  generally  cause  the  expansion  of  the  upper  arch 
througli  the  influence  of  the  occlusion.     Especially  is  this  true  with 


LATERAL   EXPANSION,    LOWEli   AKCH 


123 


yoiino'  patients.  For  this  reason  methoits  of  exi)anding  the  lower 
arch  will  lirst  be  considered. 

Lateral  Expansion  of  the  Lower  Auch. — In  expanding  the  lower 
arch  the  force  should  be  applied  gradually,  as  the  purpose  is  to 
enlarge  the  circle  without  bending  outward  the  body  of  the  jaw. 
With  the  child,  interstitial  and  general  growth  of  the  jaw  is  encour- 
aged by  expansive  force  on  the  teeth.  It  is  obvious  that  an  appliance 
for  spreading  the  lower  arch  should  not  extend  below  the  gum  line, 
as  the  tissues,  having  been  thoroughly  protected  by  the  tongue,  are 
tender,  and  the  pressure  of  a  plate  is  not  usually  tolerated  without 
more  or  less  rebellion  on  the  part  of  the  patient,  especially  if  the 
arch  is  to  be  much  expanded. 

There  is  no  advantage  in  extending  the  appliance  over  the  gum  in 
any  ordinary  case,  as  the  alveolar  process  will  follow  the  movement 
of  the  teeth  and  surround  them  in  their  new  position  ;  but  if  the 
expansion  of  the  arch  be  required  at  about  the  time  of  the  eruption 
of  the  bicuspids,  and  the  deciduous  molars  are  still  in  position,  it  is 
occasionally  advisable  to  have  the  appliance  extend  over  the  process 
to  insure  its  steady  movement  outward  with  the  erupting  bicuspids. 
Again,  the  extension  of  the  appliance  is  sometimes  an  advantage  in 
securing  anchorage  for  unilateral  expansion  of  the  lower  arch.  In 
this  case  the  apparatus  should  extend  below  the  margin  of  the  gum  on 
one  side,  thus  strengthening  the  anchorage  for  the  movement  of  the 
teeth  on  the  opposite  side. 

!•  IG.  80. 

A  simple  form  of  appliance 
for  expanding  the  lower  arch 
laterally  is  constructed  as 
shown  in  Fig.  85.  Partial- 
clasps  are  fitted  to  the  lingual 
side  of  each  of  the  teeth  to 
be  moved,  and  a  spring-clasp 
over  one  or  two  teeth  on 
either  side  of  the  arch  as  re- 
quired for  anchorage.  When 
the  deciduous  teeth  are  pres- 
ent the  spring-clasp  attach- 
ment may  be  made  to  pass  over  the  second  deciduous  molars,  and  if 
the  bicuspids  are  erupted,  the  spring-clasp  attachments  should  pass 
over  the  first  bicuspids  and  the  first  permanent  molars.     The  two 


124  EXPANSION  OF  THE  DENTAL  ARCH 

sides  of  the  api)liance  are  connected  \vith  a  lingual  base-wire,  about 
No.  13  Brown  6^  Sharpens  standard  wire  gauge,  formed  to  the  circle 
of  the  arch  and  passing  just  back  of  the  incisors.  When  the  base- 
wire  is  short,  a  smaller  size  is  sometimes  employed  to  advantage. 
The  base-wire  can  be  formed  to  rest  below  the  margin  of  the  gum, 
but  not  too  low,  as  it  would  interfere  with  the  action  of  the  tongue. 
With  the  base-wire  in  this  position,  pronunciation  is  not  interfered 
Avith.  The  ends  of  the  base-wire  extend  backward,  and  are  attached 
with  solder  to  the  anchorage  portion  of  the  appliance,  about  midway 
from  front  to  back.  The  attachment  of  the  base-wire  to  the  an- 
chorage in  this  manner  permits  of  its  being  shaped  to  give  the 
required  force  for  the  general  expansion  of  the  arch,  or  for  expanding- 
the  anterior  or  distal  part  of  the  arch  as  desired. 

When  the  apparatus  is  properly  fitted  and  inserted,  the  spring- 
clasps  are  shaped  to  clasp  the  teeth  lightly  for  anchorage.  No 
pressure  should  be  caused  by  the  appliance  for  three  days  after  its 
adjustment,  or  until  no  discomfort  is  experienced  from  it. 

The  changes  in  the  shape  of  the  spring  base-wire  for  applying  force 
are  generally  made  once  or  twice  a  week ;  in  other  cases,  but  once 
in  two  or  three  weeks.  With  this,  as  with  all  other  apparatus,  the 
force  is  to  be  increased  gradually, — that  is,  the  form  of  the  spring 
should  be  changed  only  a  little  at  a  time.  This  can  be  managed  by 
the  aid  of  a  carefully  prepared  tracing  or  chart. 

Usually  after  the  arch  has  been  expanded  the  incisors  gradually 
take  a  good  line  ;  but  if  not,  a  properly  shaped  spring,  as  a  curved 
finger-spring,  can  be  attached  to  the  base-wire  or  to  the  anchorage 
portion  on  one  or  both  sides,  and  can  be  made  to  extend  forward 
and  give  force  for  their  correction.  After  the  expansion  of  the  arch 
the  same  or  a  similar  apparatus  is  used  for  retaining. 

Fig.  86  illustrates  an  appliance  that  was  used  for  broadening  the 
lower  arch  in  the  case  of  Miss  G.,  aged  thirteen  years.*  It  was  con- 
structed on  a  plaster  model  of  the  teeth  by  shaping,  with  the  contour- 
ing pliers,  partial-clasps  of  gold  plate  (No.  34  gauge)  to  fit  the  lingual 
sides  of  all  of  the  teeth  to  be  moved.  Spring-clasps  were  then  made 
to  encircle  the  first  bicuspids  and  the  lirst  molars,  forming  spring- 
clasp  attachments  for  ancliorage. 

A  sj^ring  Ijase-wire,  No.  14  gauge,  was  sliaped  so  that  about  one- 

*  Jackson,  Items  of  Interest,  1900,  p.  074. 


LATERAL   EXPANSION,    LOWER  ARCH 


125 


inch  of  the  wire  followed  the  lingual  curve  of  the  gum  surface  back  of 
the  lower  teeth,  considerably  below  the  line  of  the  margin  of  the  gum, 
but  not  so  low  as  lo  interfere  with  llic  action  of  the  tongue.  Each 
end  of  the  wire  was  bent  forward  ui)on  itself,  and  again  backward, 


Fig.  86. 


forming  in  close  but  gentle  curves  the  shape  of  the  letter  S,  as 
seen  in  the  figure,  with  the  distance  between  the  ends  of  the  loops 
in  each  of  the  S-shaped  sections  about  one-half  inch.  The  ends  of 
the  spring  base-wire  were  then  fitted  to  the  partial-clasps  with  the 
ends  of  the  spring-clasps  on  either  side  of  the  arch,  and  soldered  with 
a  high  grade  of  soft  solder. 

The  base-wire,  shaped  in  this  manner  on  each  side  of  the  median 
line,  like  a  letter  S,  permits  the  necessary  changes  for  broadening 
the  arch  to  be  made  without  warping  the  apparatus  or  interfering 
with  the  established  relationship  of  the  anchorage  portions  with  the 
teeth  that  they  are  made  to  clasp.  The  appliance  is  not  as  easily  made 
or  manipulated  as  the  one  previously  described,  but  it  is  effective. 

The  action  is  changed  by  bending  outward  from  time  to  time  the 
loops  in  the  spring  base-wire.  This  is  done  in  the  following  man- 
ner :  Hold  the  end  of  one  of  the  lower  loops  firmly  with  flat- 
nosed  pliers  and  bend  tlie  wire  by  pressing  outward  with  the  hand 
the  anchorage  portion.  Then  take  the  corresponding  upper  looped 
portion  of  the  wire  in  the  pliers  and,  holding  firmly  with  the  other 
hand  the  short  central  part  of  the  wire  that  rests  back  of  the  front 
teeth,  press  it  outward  with  the  pliers  a  little  to  make  this  part  corre- 
spond with  the  first.     When  it  is  desirable  to  increase  the  pressure, 


126 


EXPANSION  OF  THE  DENTAL  ARCH 


Fig.  87. 


the  double  loop  on  the  opposite  side  of  the  median  line  should  be 
bent  as  described.  These  changes  should  be  made  usually  about 
once  a  week. 

When  the  teeth  of  the  lower  arch  are  of  good  form  for  anchor- 
age, an  appliance  for  expansion  like  Fig.  87  will  meet  the  require- 
ments without  the  addition 
of  spring- clasps.  The  motiel 
should  be  very  accurate.  The 
appliance  is  made  by  fitting 
partial-clasps  to  the  model  on 
■r-^r  v'i':i%^^**s  -1^        the  lingual  side  of  each  of  the 

/  ■i»w''iri\     teeth  to  be  moved.     A  spring 

"^/  :ll^-4^^   base-wire  with   a   loop   in  the 

centre  pointing  downward,  and 
sufficiently  large  to  cause  the 
necessary  expansion,  is  to  be  formed  to  follow  the  lingual  sides  of 
the  teeth  in  contact  with  the  partial-clasps  to  which  it  is  soldered. 
The  appliance  is  so  shaped  as  not  to  impinge  on  the  gum. 

If  at  any  time  the  anchorage  proves  insufficient,  spring-clasps  can 
readily  be  added. 

The  following  case  illustrates  the  possibilities  and  the  advantages 
of  early  regulation  of  the  teeth.  Master  S.,  aged  seven  years ;  all 
of  the  deciduous  teeth  in  position  excepting  four  of  the  incisors. 
Three  permanent  incisors  and  tlie  four  first  permanent  molars  were 
erupting.  The  upper  arch  was  unusually  large  ;  the  lower  arch  was 
very  much  contracted,  all  of  the  teeth  closing  inside  of  the  circle  of 
those  in  the  upper  arch,  with  the  lower  incisors  impinging  on  the  gum. 
The  child  was  unable  to  carry  on  any  ordinary  mastication,  and  was 
ansemic  and  very  nervous.  On  April  9  a  palatine  plate,  with  an 
elevated  ridge  on  the  front  and  sides,  was  inserted  in  the  upper 
arch,  forming  an  occlusal  surface  for  the  lower  teeth.  This  immedi- 
ately provided  means  for  natural  mastication. 

Fig.  88  illustrates  the  upper  arch  (natural  size)  with  the  plate  in 
position.  The  dotted  lines  indicate  the  surface  covered  by  the  lower 
teeth  in  occlusion.  Fig.  89  shows  the  lower  arch  (actual  size),  with 
an  appliance  inserted  for  its  expansion.  The  deciduous  teeth  were 
very  short,  the  gum  covering  about  two-thirds  of  the  crowns  of  the 
permanent  molars.  The  appliance  was  made  on  the  principle  of  the 
one  shown  in  Fig.  85.     Force  was  applied  by  bending  outward  the 


LATERAL  EXPANSION,  LOWER  ARCH 

Fio.  88. 


127 


1-28 


EXPANSION  OF  THE  DENTAL  ARCH 


Fig.  92. 


sides  of  tiie  lingual  base-wire  at  intervals,  usually  about  once  a  week. 
The  lower  permanent  lateral  incisors  erupted  far  back  of  the  normal 
position.  To  move  outward  the  laterals  and  the  central  incisors, 
after  the  arch  was  partially  expanded  laterally,  a  curved  finger- 
spring,  extending  forward,  was  attached  to  the  anchorage  portion  on 
either  side. 

Fig.  90  shows  the  upper  arch  with  the  advanced  development  of 
the  permanent  incisors  on  January  19.  Fig.  91  illustrates  the 
lower  arch  in  its  expanded  condition  (actual  size)  on  March  20, 
the  teeth  having  taken  a  natural  occlusion  with  the  upper  teeth. 
The  same  form  of  appliance  was  continued  in  use  as  a  retainer. 
The  difference  in  the  width  of  the  arches  and  the  extent  of  tlie  ex- 
pansion is  indicated  by  the  lines  «,  a,  6,  b.  This  extensive  change 
was  made  with  but  little  discomfort  to  the  patient. 

Fig.  92  illustrates  an  apparatus  recommended  by  Dr.  Norman  W. 
Kingsley*  for  the  lateral  expansion  of  the  lower  arch.     It  is  made 

of  vulcanite,  and  is  fitted  to  the  lingual 
sides  of  the  teeth  like  a  partial  plate. 
A  jack-screw  witli  a  nut  is  inserted,  the 
vulcanite  being  split  with  a  saw  in  such 
a  manner  that  the  turning  of  the  screw 
forces  outward  one  part  of  the  sepa- 
rated vulcanite,  thus  causing  the  move- 
ment of  the  teeth.  The  screw  is  turned 
once  or  twice  daily.  It  can  be  adjusted 
for  causing  the  outward  movement  of  both  sides  of  the  arch,  or  for 
one  side  only,  as  illustrated. 

A  method  of  expanding  the  upper  or  lower  arch  with  a  vulcanite 
divided  plate  connected  with  piano-wire  springs  (Figs.  93  and  104) 
was  described  by  Mr.  W.  H.  Coffin  in  a  paper  read  before  the  Inter- 
national Medical  Congress  in  London,  August,  1881. f  Mr.  Coffin 
stated  that  the  method  had  been  in  use  ])y  his  father  and  himself 
for  twenty-five  years. 

The  plate  is  made  of  vulcanite,  divided  through  the  centre  into 
lateral  halves,  which  are  connected  with  springs  of  i)iano-forte  wire. 


*  Kingsley's  Oral  Dofoniiilifts,  p.  71. 

f  Coffin,  Transactions  Seventh  Internationul  Medical  Congress,  London,  1881, 
vol.  iii.  1).  542. 


LATERAL  EXPANSION,  UPPER  ARCH 


129 


Fui.  <«. 


The  vulcanite  usually  extends  from  the  Unj^ual  side  over  the  grinding 

surface  of  the  molars  and  bicuspids,  covering  the  buccal  side  of  the 

teeth  so  that  when  the  plate  is  inserted  it  will  clasp  them  sufficiently 

well  to  insure  good  anchorage.     For  the  expansion   of  the   lower 

arch,  the  lateral  halves  of 

the  plate    are    connected 

with   one  or  two  curved 

piano- wire  springs,  having 

their  ends   flattened    and 

embedded  in  the  vulcanite 

opposite  the  bicuspids  or 

molars.     (See  description 

of  the  metliod  of  making 

these  appliances  on  page 

136.) 

For  anterior  expansion  of  the  lower  arch  see  page  144- 

Lateral  Expansion  of  the  Upper  Arch. — A  simple  device  for  the 

lateral  expansion  of  the  upper  arch  is  made  as  seen  in  Fig.  94.    For 

anchorage,  partial-clasps  are 
^'''-  ^^-  fitted  to  the  palatal  surface 

of  the  teeth  to  be  moved, 
with  a  spring-clasp  on  one 
or  two  teeth  on  each  side. 
These  are  connected  with  a 
lingual  base-wire,  about  No. 
13  gauge,  formed  to  the  circle 
of  the  arch  and  passing  just 
back  of  the  incisors  when 
the  articulation  will  permit. 
The  ends  extend  backward 
and  are  attached  with  solder 
to  the  centre  of  the  anchor- 
age portion. 
The  necessary  force  is  applied  by  removing  the   appliance  from 

time  to  time,  and  bending  outward  a  little  the  ends  of  the  base-wire. 

If  the  anterior  part  of  the  arch  needs  to  be  expanded  laterally  more 

than    the  distal,  or  vice  versa,  the  shape  of   the  base-wire  can  be 

changed  for  that  purpose  by  bending  it  near  where  it  enters   the 

anchorage  portion. 


130 


EXPANSION  OF  THE  DENTAL  ARCH 


The  base-wii'e  passing  on  the  })alatal  side  of  the  upper  incisors  in 
this  manner  occasionahy  interferes  with  the  articulation  of  the 
sounds  t,  d,  and  s,  as  the  tongue  touches  tlie  gum  at  about  that  posi- 
tion. If  the  patient  has  trouble  in  this  respect,  or  if  the  lower  in- 
cisors close  too  near  the  gum  to  admit  of  the  base-wire  passing  at 
this  point,  a  palatine  base-wire  can  be  employed  with  a  U-shaped 
loop  formed  in  the  centre  (Fig.  95).     The  ends  of  the  base-wire  are 

soldered  to  the  spring-clasp 
attachments  on  either  side 
for  anchorage.  Force  is  pro- 
duced by  opening  the  loop 
in  the  base-wire  from  time 
to  time. 

The  palatal  surface  of  the 
cuspid  inclines  outward  in 
some  cases  to  such  an  extent 
that  the  anterior  part  of  the 
apparatus  is  not  well  re- 
tained. This  is  obviated  by 
'  ^^^^^  arranging  a  wire  to  extend 

forward  from  the  ancliorage 
portion  of  the  apparatus,  with  the  end  curved  to  rest  on  the  mesio- 
palatal  surface  of  the  cuspid  encroaching  on  the  gum.  If  it  is  not 
held  in  position  by  the  shape  of  the  cuspid,  sometimes  a  narrow  con- 
toured partial-clasp  fitted  well  under  the  free  margin  of  the  gum  and 
soldered  to  the  wire  will  improve  the  anchorage  ;  or  a  collar  with  a 
suitably  shaped  lug  can  be  cemented  to  the  cuspid  and  the  angle  of 
the  wire  changed  as  desired  to  fit  under  the  lug. 

Although  usually  but  slight  persistent  force  is  required  for  expand- 
ing tlie  arch,  two  palatine  base-wires  are  sometimes  of  advantage. 

An  effective  ap|)liance  is  made  with  one  spring  base-wire  crossing 
the  arch  in  line  with  the  cuspids  or  bicuspids,  and  the  other  in  the 
line  of  the  molars.  Each  base-wire  can  have  a  loop  formed  in  the 
centre,  or  the  base-wire  may  be  made  without  a  definite  loop,  being 
bent  backward  opposite  the  median  line.  When  force  is  required, 
they  can  be  bent  forward  slightly  at  intervals  to  lengthen  them. 

The  advantage  of  using  the  round  spring  base-wire  is  noticeable 
in  these  forms  of  appliance,  as  the  sjiring  can  be  bent  in  any 
direction  for  causing  the  necessary  force  without  warping  the  ap- 


LATERAL   EXPANSION,  UPPER  ARCH 


131 


pliance,  which  would  occur  if  tho  spring  were  made  of  flat  or  square 
metal. 

Generally,  in  expanding  the  arch  it  is  found  that  the  distal  part  is 
broad  enough,  and  only  the  region  of  the  cuspids,  bicuspids,  and 
first  molars   needs   to   be   expanded  (Fig.    96).     In   such  a  case  a 
palatine   base-wire    should    be 
arranged  in  the  distal  part  of 
the  arch,  where  it  is  already 
broad   enough,  with   the   ends 
attached  in  the  anchorage. 

To  the  anterior  part  of  the 
anchorage  portion  on  each 
side  is  soldered  a  small  wire, 
shaped  to  follow  the  lingual  side 
of  the  cuspids,  encroaching  on 
the  gum,  the  end  being  curved 
to  engage  with  the  mesio-pala- 
tal  surface.  Force  for  expan- 
sion is  caused  by  pressing  out- 
ward on  the  anterior  arms  of  the  anchorage,  bending  the  base-wire. 

With  this  style  of  device,  when  the  distal  part  of  the  arch  needs 
to  be  expanded  also,  the  palatine  base-wire  should  be  arranged  to 


cross  far  back,  with  the  ends  curved  forward,  forming  arms  shaped 
to  enter  the  anchorages  opposite  the  second  bicuspids  or  first  molars 
(Fig.  97).     Force  is  supplied  by  bending  outward  the  arms  of  the 


132 


EXPANSION  OF  THE  DENTAL   AKCH 


base-wire.    The  arch  is  held  in  the  same  relationship  until  sufficiently- 
expanded,  when  the  teeth  are  evened. 

In  expansion,  when  the  teeth  are  moved  to  a  considerable  extent, 
it  is  sometimes  difficult  to  harmonize  the  teeth  of  the  upper  arch 
with  those  of  the  lower  to  form  a  good  and  permanent  occlusion. 
Fig.  98  illustrates  an  expanding  and  equalizing  device  in  the  upper 

Fig.  98. 


arch,  with  flanges  attached  projecting  downward  from  the  palatal 
surface  on  either  side.  The  appliance  is  made  with  partial-clasps 
and  spring-clasp  attachments  connected  with  one  or  two  large  pala- 
tine spring  base-wires.  Spurs  are  extended  from  the  device  on 
to  the  grinding  surface  of  the  upper  teeth  to  prevent  the  appa- 
ratus from  being  pressed  against  the  gum.  The  flanges  (a,  a)  are 
made  of  plate-metal  and  shaped  to  project  sufficiently  on  to  the 
lingual  surface  of  the  lower  molars,  bicuspids,  and  cuspids  in  occlu- 
sion, to  guide  and  cause  them  to  articulate  with  the  upper  ones.  In 
locating  the  flanges  it  is  well  to  take  a  bite,  as  for  making  artificial 
teeth.  Their  general  contour  can  be  crimped  to  fit  the  lower  teeth, 
or  left  smooth.  The  flanges  should  be  thickened  with  solder  and  the 
edges  rounded  sufficiently  to  prevent  irritation  of  the  tongue.  Bend- 
ing outward  the  base-wire  slightly  from  time  to  time  broadens  both 
the  upper  and  lower  arches.  The  flanges  can  be  bent  outward  or 
inward  as  required  to  further  adjust  the  occlusion.  When  desirable 
the  flange  can  also  be  extended  around  the  anterior  part  of  the  arch, 
as  for  correcting  a  receding  lower  jaw.  For  some  conditions,  the 
flanges  may  best  be  made  to  project    in    the    form    of  flat   metal 


LATERAL   EXPANSION,  UPPER   ARCH 


133 


Fig.  99. 


springs.  Tho  device  is  applicable  in  the  lower  arch  by  the  use  of  a 
hngual  base-wire. 

Fig.  99  shows  the  position  of  the  teeth  of  Miss  A.,  aged  sixteen 
years,  when  presented  for  treatment.  Only  one  of  the  teeth  hi  the 
upper  arch,  a  back  molar, 
articulated  with  those  of 
the  lower  for  mastication, 
the  others  closing  inside 
of  the  line  of  the  teetli 
of  the  lower  arch.  The 
patient  had  been  a  mouth- 
breather  from  infancy  as 
a  result  of  nasal  steno- 
sis   caused     by    adenoid 

growths  and  thickening  of  the  mucous  membrane  of  the  nose.  She 
was  advised  to  visit  a  rhinologist  and  have  the  abnormal  conditions 
corrected  to  permit  free  nasal  breathing,  and  later  to  have  the  upper 
arch  expanded  to  cause  the  teeth  to  occlude  with  the  lower  ones. 

Fig.  100  is  a  view  of  the  palatine  arch  before  treatment.     As  the 
arch  was  to  be  much  expanded,  it  was  determined  to  force  outward 


Fig.  100. 


the  bony  process  with  the  teeth.  A  vulcanite  split  plate  connected 
with  a  U-shaped  spring  was  made,  anchored  with  wire-clasps  extend- 
ing from  the  plate  around  the  upper  bicuspids,  and  with  platina-gold 
collars  cemented  to  each  of  the  central  incisors  and  cuspids,  with  lugs 
on  the  palatal  side  shaped  to  project  a  little  over  the  plate. 


134 


EXPANSION  OF  THE  DENTAL  ARCH 


Fig.  101  illustrates  the  plate  used  and  the  extensive  change  made 
in  the  shape  of  the  arch  by  moving  the  teeth  and  process  bodily 


Fig.  101. 


outward.  As  the  expansion  of  the  arch  progressed  the  front  edge 
of  the  plate  pressed  on  the  palato-distal  side  of  the  central  incisors, 
and  a  small  spring-wire  was  attached  in  each  side  of  the  plate  to 
extend  forward  to  the  mesial  and  labial  side  to  rotate  them  inward. 
When  the  incisors  were  rotated  to  proper  position,  they  were 
retahied  by  cementing  to  them  platina-gold  collars  that  had  been 
fitted  to  the  teeth  and  soldered  together  at  the  median  line,  as 
recommended  by  Dr.  Guilford.  When  the  upper  arch  was  ex- 
panded the  teeth  articulated  with  those  in  the  lower  arch,  as  seen 

Fig.  102. 


-v«aij^7«.v.vj: 


^ii^W 


in  Fig.  102.  A  retaining  plate  of  thin  vulcanite  was  then  inserted 
and  worn  about  two  years,  when  the  patient  wns  instructed  to  leave 
it  out  during  the  day  and  insert  it  regularly  before  retiring. 


LATERAL  EXPANSION,  UlTER   AliCH  135 

Usually  one  niodium-sizcd  spring  connecting  the  lateral  halves  of 
a  plate,  as  illustrated,  is  sufticient  for  expanding  the  arch;  but  if  it  is 
found  in  the  early  stage  of  the  operation  that  sufficient  force  is  not 
being  generated,  a  second  spring  may  be  bent  into  a  U-shaped  loop, 
with  the  ends  curved  outward  and  shaped  to  enter  holes  made  in 
the  j)late  for  the  purpose. 

If  from  any  cause  the  growth  of  the  upper  maxilla  has  been 
arrested,  the  early  expansion  of  the  arch  encourages  the  develop- 
ment of  the  jaw  and  also  broadens  and  increases  the  air-passage  of 
the  nares.  The  changes  brought  about  by  the  expansion  of  the  arch 
later  in  life  are  dependent  principally  upon  the  movement  of  the  teeth 
and  process. 

After  the  formative  stage  of  tlie  jaw  lias  passed,  the  rapid  and 
forcible  expansion  of  the  arch,  as  by  the  use  of  a  jack-screw,  not 
infrequently  separates  the  maxilla  at  the  suture  at  the  median  line. 
This  is  thought  by  some  practitioners  not  to  be  objectionable,  but  I 
have  seen  several  cases  accompanied  with  a  degree  of  congestion 
that  certainly  did  not  encourage  the  desired  bony  deposit  in  those 
parts.  This  unpleasant  result  has  not  been  observed  to  follow  the 
use  of  gradual  spring-pressure. 

Jack-Screw. — The  jack-screw  for  the  correction  of  irregularities  of 
the  teeth  is  tliought  to  have  been  introduced  by  Dr.  William  Dwindle 
about  the  year  1849.  He  first  made  it  of  gold,  but  later  used  steel 
on  account  of  its  greater  strength.  He  discovered  that  by  placing  a 
small  amount  of  zinc  in  a  hole  in  the  end  of  the  screw  device  its 
oxidation  was  prevented. 

The  jack-screw  has  been  used  successfully  by  many  practitioners, 
and  is  still  recommended  in  recent  text-books  and  journals  for 
expanding  the  arch  and  moving  individual  teeth.  It  is  described 
as  being  attached  to  the  teeth  with  cemented  bands,  ligatures,  at- 
tached to  plates,  etc.,  and  crossing  tiie  arch  in  many  directions.  It 
will  be  observed,  however,  for  obvious  reasons,  that  it  is  seldom 
recommended  by  its  advocates  for  moving  the  teeth  of  the  lower 
arch. 

I  have  not  found  the  jack-screw  of  especial  value  in  any  case,  and, 
owing  to  its  interference  with  the  tongue  in  pronunciation  and  mas- 
tication, suggest  that  its  use,  both  for  pushing  and  pulling  the  teeth, 
be  discontinued  in  favor  of  methods  more  agreeable  to  the  patient. 
Realizing,  however,  that  some  operators  employ  it,  my  system  of 


136 


EXPANSION   OF  THE  DENTAL  ARCH 


'*ii\,.i^" 


anchorage  for  holding  the  jack-screw  in  position  in  ahiiost  any  part 
of  the  mouth  will  be  described,  showing  especially  how  to  form  the 
anchorage  for  expanding  the  arch  with  a  jack-screw  made  of  steel 
or  other  metal. 

For  this  purpose  partial-clasps  and  spring-clasp  attachments  should 
be  arranged   on   the  teeth  chosen  for  anchorage  (Fig.   103).     The 

jack-screw  is  then  placed  in  po- 
^"^''  ^*^^"  sition  across  the  arch,  and  soft 

solder  flowed  with  the  soldering 
iron  over  the  end  of  it  and  the 
metal  constituting  the  anchorage 
portion  joining  them.  The  nut 
that  forms  a  portion  of  the  jack- 
screw  can  thus  be  secured  at 
either  end  in  the  position  de- 
sired. This  not  only  makes  a 
firm  anchorage,  but  permits  the 
easy  removal  of  the  device  for 
cleansing  and  making  the  neces- 
sary changes. 
CoflBin  Plate  (Fig.  104). — In  making  an  apparatus  after  the  Coffin 
method  for  expanding  the  upper  arch,  an  accurate  model  is  first 
made.  A  wax  try-plate  is  formed  on  the  model,  in  the  shape  de- 
sired for  the  plate.  It  should  cover  the  palatine  arch  and  extend 
over  tlie  grinding  surface  of 

the  molars  and  bicuspids  to  ■^'"-  ^^'*- 

the  buccal  side,  enclosing 
them  and  fitting  the  necks 
of  the  teeth  sufficiently  well 
to  insure  good  anchorage. 
The  plate  cannot  be  made 
to  fit  satisfactorily  unless  the 
model  is  a  perfect  one.  The 
impression  slionld  usually  be 
made  with  jjjaster  of  Paris.  Mr.  Coffin  recommended  for  this 
purpose  taking  the  impression  with  gutta-perclia :  making  it  very 
hot,  then  plunging  it  in  cold  water  to  cool  the  surface  just  before 
being  pressed  firmly  into  position  in  the  moutli.  If  eiijier  the 
impression   or  the  model  is  srrajjed  or  changed,  the  vulcanite  plate 


LATERAL   EXPANSION,  UPPER   ARCH  137 

when  finished  will  need  to  be  dressed  correspondingly;  therefore 
they  should  not  be  interfered  with  more  than  is  necessary  to  guard 
against  excessive  undercuts,  etc.,  which  always  requires  tlie  dress- 
ing of  the  apparatus.  Mr.  Coffin  suggests  the  use  of  small-sized 
spring-wire  for  regulating  purposes  and  for  spreading  tlie  arch,  and 
recommends  that  the  spring  for  connecting  the  lateral  halves  of  the 
plate  be  made  of  piano-forte  wire  of  a  diameter  between  three- 
himdredths  and  four-hundredths  of  an  inch,  bent  into  a  three-  or 
five-curve  serpentine  figure  like  a  rounded  capital  W,  and  shaped 
to  conform  to  the  surface  of  tlie  plate  ;  flattening  the  ends  of  the 
springs  where  they  are  to  enter  the  vulcanite.  When  the  spring 
is  ready  to  be  placed  in  position,  a  thick  piece  of  tin-foil  is  spread 
smoothly  on  the  try-plate  underneath  the  spring  portion,  and  the 
flattened  end  is  embedded  in  the  wax.  The  corners  of  the  tin-foil 
are  then  bent  up,  so  that  when  the  plaster  is  poured  into  the  flask 
it  will  run  about  the  foil  and  hold  it  and  the  wire  in  position  in  the 
upper  part  of  the  flask  when  removed.  The  foil  also  insures  a 
polished  surface  to  the  plate  under  the  loops  of  the  wire  after  the 
vulcanizing  process. 

This  or  other  springs  can  be  held  in  position  in  the  flask  by 
placing  around  them  iron  binding-wire  and  letting  the  ends  extend 
into  the  plaster  instead  of  the  tin-foil,  if  preferred. 

The  plate  when  finished  should  be  fitted  to  the  mouth,  then 
divided  in  half  along  the  median  line  with  a  fine  saw,  and  the  edges 
smoothed  carefully  so  as  not  to  twist  the  spring.  Expansive  force 
is  exerted  by  opening  the  loops  from  time  to  time.  An  appliance 
for  the  lower  arch  is  made  in  a  similar  manner  (Fig.  93). 

Mr.  Coffin  recommends  that  the  ends  of  the  wire  that  are  to  be 
embedded  in  the  vulcanite  be  tinned  or  coated  with  soft  solder.  The 
steel  is  most  liable  to  corrode  at  the  point  where  it  enters  the  vulcanite, 
and  the  tin  or  lead  covering  may  lessen  this  tendency.  The  central 
portion  of  the  connection-spring  can  be  made  into  a  single  loop  if  pre- 
ferred, and  other  springs  can  be  added  for  moving  any  especial 
teeth. 

The  part  of  the  plate  that  forms  the  grinding  surface  should  be 
shaped  to  make  a  good  articulation  with  the  teeth  of  the  opposite 
arch.  It  has  been  recommended  that  the  surface  be  roughened  to 
assist  mastication. 

The  writer  lias  used   the  Coffin  method  with   much  satisfaction 


138  EXPANSION  OF  THE  DENTAL  ARCH 

since  the  introduction  of  the  system  into  this  country,  but  was 
early  impressed  with  tlie  following  objections  to  covering  the  teeth 
with  rubber: 

First,  on  account  of  its  interfering  with  the  speech  and  comfort 
of  the  patient. 

Second,  it  endangers  the  articulation  of  the  bicuspids  and  molars, 
especially  where  the  appliance  is  to  be  worn  several  months,  some- 
times producing  detrimental  changes  in  the  occlusion  that  would 
not  have  taken  place  had  the  teeth  of  one  arch  been  allowed  to 
articulate  with  those  of  the  other  during  their  movement. 

Third,  the  shape  of  the  plate,  having  deep  depressions  on  either 
side  for  the  accommodation  of  the  teeth,  is  unfavorable  to  cleanli- 
ness, it  being  difficult  for  the  patient  to  keep  it  in  an  aseptic  condition, 
and  the  teeth,  therefore,  being  more  liable  to  decay  from  the  decom- 
position of  the  accumulating  saliva  and  food  particles. 

Fourth,  opening  the  bite  assists  the  regulation  of  the  teeth  only 
in  a  limited  number  of  cases. 

For  these  reasons  I  have  adopted  a  modified  form  of  split  plate,* 
which  does  not  cover  the  teeth,  the  anchorage  being  gained  either 
by  wire-clasps,  spring-clasps,  or  collars  with  lugs  (Figs.  68  and  101); 
or  by  a  wire-clasp  extended  directly  over  the  arch  at  the  junction 
of  the  teeth  at  any  place  the  articulation  will  permit  to  rest  on  the 
buccal  side,  as  seen  in  Fig.  112.  It  is  an  advantage  in  some  instances 
to  move  the  process  with  the  teeth,  and  the  separation  of  the  pala- 
tine plate  can  be  made  in  any  direction  most  favorable  for  accom- 
plishing the  result  desired  (Fig.  199). 

Unilateral  Expansion. — With  the  narrow  arch  the  articulation  of 
the  teeth  is  occasionally  such  as  to  make  it  desirable  that  only  one 
side  should  be  moved. 

In  the  process  of  expansion  this  can  be  accomplished  with  an 
appliance  made  as  seen  in  Fig.  105.  It  is  applicable  for  the  upper 
or  lower  arch.  A  spring  base- wire  is  shaped  to  follow  the  lingual 
curve ;  one  end  is  anchored  by  a  spring-clasp  attachment  to  a  tooth 
that  is  to  be  moved,  and  the  other  end  by  spring-clasp  attachments 
to  one  or  more  teeth  on  the  opposite  side  of  the  arch.  This  portion 
of  the  anchorage  can  be  fortified  by  extending  rubber  vulcanite  or 
metal  from  it  to  cover  more  or  less  of  the  gum  and  process. 


*  Jackson,  Dental  Cosmos,  1890,  p.  879. 


UNILATERAL   EXPANSION,  UPPER  ARCH 


139 


Wlien  both  sides  of  the  arch  require  to  be  moved  equally,  and  it 
is  found  that  only  one  side  is  moving-,  I  his  form  of  anchorage  is 
applicable  by  attaching  the  metal  or  vulcanite  to  the  appliance  on 
tiie  side  that  is  moving  too  rapidly. 

Metal  can  be  added  to  an  Fig.  105. 

api)liance  at  any  time  for 
this  purpose  by  placing  it 
on  a  model  of  the  mouth 
in  exact  position  and  flow- 
ing soft  solder  over  the 
parts  with  a  soldering  iron, 
shaping  it  in  the  form  de- 
sired. 

Metal  gauze  or  plate- 
metal  is  sometimes  em- 
ployed. In  this  case  it  will 
be  observed  that  all  of  the 

force  was  first  exerted  on  but  one  tooth,  the  second  left  upper 
bicuspid,  and  later  a  small  spring  was  engaged  with  tlie  adjoining 
teeth  for  moving  them  outward. 

Fig.  106  shows  an  appliance  used  to  expand  the  upper  arch  later- 
ally for  Miss  H.,  aged  fourteen  years.  The  condition  of  the  articula- 
tion required  that  only  one  side  should  be  moved. 

The  appliance  was  made  by 
Fig.  106.  ^^  '' 

arranging   a    palatine    spring 

base-wire.  No.  12  gauge,  hav- 
ing a  U-shaped  loop  about 
half  an  inch  long  pointing 
towards  the  palate,  with  the 
ends  of  the  base-wire  curved 
backward  and  ancliored  witli 
a  spring-clasp  attachment  over 
the  first  bicuspid  and  first 
molar  on  either  side.  The 
part  of  the  appliance  on  the 
side  that  was  not  to  be  moved 
had  tlie  anchorage  fortified  by  attaching  to  it  with  solder  a  swaged 
metal  plate,  extending  upward  from  the  spring-clasp  attachments  to 
cover  a  good  portion  of  the  side  of  the  palatine  arch.     When  con- 


140 


EXPANSION   OF  THE   DENTAL  ARCH 


siderable  force  is  to  be  exercised  the  plate  portion  sliould  be  quite 
broad,  the  loop  in  the  base-wire  being  opened  slightly  from  time  to 
time  as  required. 

Unilateral  prognathism  is  not  uncommonly  met  with.  Fig.  107 
illustrates  a  case  that  was  brought  about  by  the  injudicious  extrac- 
tion of  a  left  upper  molar,  causing  an  arrest  of  development  on  that 
side  of  the  arch,  the  lower  jaw  continuing  its  normal  development 
until  finally  all  of  the  left  lower  teeth  closed  outside  of  the  upper 
ones,  at  the  same  time  drawing  forward  the  right  side  of  the  lower 
jaw.  The  unilateral  expansion  of  the  upper  arch  and  the  applica- 
tion of  a  chin-cap  was  reconmiended. 

Fig.  108  shows  the  position  of  the  teeth  of  Mr.  G.,  aged  forty-one 
years. 

The  left  upper  cuspid  and  the  lateral  and  central  incisors  closed  far 
inside  of  the  lower  arch,  the  lower  cuspid  and  incisors  projecting  near 

Fig.  108. 


the  upper  gum  in  front  of  them,  some  of  the  teeth  being  considerably 
worn.  Several  molars  and  bicuspids  of  the  upper  and  of  the  lower 
arcli  were  absent,  making  it  somewhat  difficult  to  get  a  good  anchor- 
age for  the  correction  of  the  irregular  teeth.  A  device  was  arranged 
to  open  the  bite  to  facilitate  tlie  movement,  and  at  tlie  same  time 
to  secure  additional  anchorage  by  making  atta(;hment  to  the  ui)per 
incisors  and  cuspid  on  the  opposite  side  of  the  arch.  A  spring- 
clasp  atlacliiiK  lit  was  arranged  over  th(^  first  led  upper  molar, 
llic  only  ri'iiiaining  anchorage  ioolli  on  tliiit  side,  and  a  spring- 
clasp    attacliment  over  the  second    right    upper    l)icnsi)id,    the    first 


Fig.  107. 


UNILATERAL   EXPANSION,  UPPER  ARCH 


141 


Fig.  109. 


bicuspid  having  been  removed,  with  partial-clasps  on  the  first  molar, 
cuspid,  lateral  and  central  incisors  (Fig.  109).  Small  short  wires  w^ere 
shaped  to  pass  over  the  incisive  edge  at  the  junction  of  the  c(;ntral 
incisors,  lateral,  and  cuspid,  resting  on  the  partial-clasps,  with  the  ends 
on  the  labial  side  ex- 
tendingperpendicularly 
towards  the  gum  to  as- 
sist the  anchorage  and 
to  prevent  the  appli- 
ance being  dislodged  in 
mastication.  The  sides 
of  the  device  were  con- 
nected by  a  palatine 
base-w'ire.  A  semicir- 
cular spring  with  two 
U-shaped  loops  was  ar- 
ranged with  the  ends 
extending  to  the  an- 
chorage portions.  All  of  the  parts  were  united  with  solder.  The  bite 
was  opened  by  building  additional  solder  onto  the  partial-clasps  on  the 
incisors  and  cuspid,  and  onto  strips  of  plate-metal,  one  extending  from 
the  cuspid  across  the  space  and  over  the  bicuspid,  and  the  other  over 
the  molar  on  the  opposite  side  of  the  arch.     The  bite  being  opened  in 

this  manner  permitted 
the  outward  movement 
of  the  instanding  teeth 
when  force  was  applied 
with  the  looped  spring. 
The  anterior  part  of 
the  spring  was  retained 
by  a  lug  on  a  collar 
cemented  to  the  cus- 
pid. The  regulating 
was  completed  in  a 
limited  time  and  with 
no  especial  discomfort 
to  the  patient.  In  Fig, 
110  is  seen  the  position  of  the  teeth,  with  partial  upper  and  lower 
plates  inserted,  which  served  for  retaining  and  filled  the  vacancies. 


Fig.  110. 


142  EXPANSION  OF  THE  DENTAL  ARCH 

When  the  lower  molars  and  bicuspids  are  absent  it  is  sometimes 

difficult  to  adjust  a  partial  plate  so  that  it  will  be  held  firmly  in  place. 

The  cuspids  are  tapering,  and  clasps  extending  forward  from  the 

plate  in  the  usual  manner  to  encircle  the  cuspids  do  not  retain  it 

well.     In  such  a  case  flat  clasps  can  be  made  to  extend  from  the 

plate  between  the  lateral  incisors  and  cuspids  to  engage  with  the 

mesio-labial  surface  of  the  latter,  or  wire-clasps  extended  over  the 

arch  at  the  junction  of 
Fig.  11].  . 

the  teeth  in  front  of  the 

■::;..,;.  i  :■-.///:..:':'■  .:M<-::-: ::, ,         cusplds    to    clasp    their 

labial  surface. 

Fig.  Ill  illustrates  the 
position  of  the  teeth  in 
the  case  of  Miss  B., 
aged  twenty-six  years,  a 
teacher  in  the  public 
school. 
The  lower  jaw  appeared  very  prominent  on  the  right  side,  other- 
wise she  was  fine-looking  and  her  features  were  quite  regular.  On 
examination  it  was  found  that  the  teeth  on  the  right  side  of  the 
upper  arch  closed  inside  of  the  line  of  the  lower  ones,  the  second 
right  upper  bicuspid  having  erupted  inside  of  the  arch,  resting  on 
the  palato-mesial  side  of  the  first  molar,  with  the  first  bicuspid  in  the 
place  of  the  second  and  in  contact  with  the  molar.  The  median  line  of 
the  lower  arch  was  to  the  right  of  the  median  line  of  the  upper  arch 
more  than  the  width  of  one  of  the  teeth.  This  condition  had  existed 
since  the  teeth  had  erupted,  and  the  incisive  edge  of  the  upper  incisors 
had  become  worn  where  they  crossed  the  arch  of  the  lower  ones. 
It  was  found,  by  measurement  of  the  models  made  of  the  teeth,  that 
if  the  first  right  upper  bicuspid,  cuspid,  lateral  and  central  incisors 
were  moved  forward  and  outward  sufficiently  to  let  the  second 
bicuspid  into  its  proper  position,  at  the  same  time  expanding  the 
arch,  the  teeth  could  be  made  to  articulate  with  those  of  the  lower, 
and  correct  the  appearance  of  the  deformity  without  operating  on 
the  lower  jaw. 

A  modified  split  j)late  (jf  vulcanite  rubber  with  springs  was  used 
to  expand  tlie  arch  and  move  the  teeth  into  position  (Fig.  112).  It 
was  anchored  with  wire-clasps  and  platina-gold  collars  with  lugs  on 
the  palatal  side  cemented   to  the   teeth.     The   appliance  was  made 


UNILATERAL  EXPANSION,  UPPER  ARCH 


143 


by  first  obtaining  an  accurate  impression  of  the  irregular  teeth.  A 
try-plate  was  formed  over  the  palatine  portion  of  the  upper  model 
in  the  usual  manner,  and  a  scratcli  made  across  the  surface  of  it  at 
the  median  line  to  tell  where  to  separate  the  vulcanite  with  the  saw 
when  the  plate  was  finished.  A  German  silver  wire,  No.  14  gauge, 
was    then    formed    into 

a  loo}),  the    loop    being  ^'^-  ^^-• 

about  one-half  inch  long 
and  fitted  to  the  surface 
of  the  try-plate,  crossing 
the  centre,  with  the  ends 
curved  and  embedded  in 
the  wax  to  connect  the 
lateral  halves  of  the  plate. 
A  portion  of  the  ends  of 
the  wire  that  entered  tlie 
vulcanite  was  first  flat- 
tened with  a  hannner  as 
shown  by  the  dotted  lines 
in  the  figure.    When  the 

spring  is  made  of  German  silver  or  gold,  the  temper  should  be  drawn 
from  that  part  of  the  spring. 

The  second  right  bicuspid  was  moved  forward  and  outward  with 
a  spring  wire.  No.  18  gauge,  formed  into  the  shape  of  a  letter  S 
and  attached  to  the  distal  part  of  the  plate.  A  platina-gold  collar, 
with  a  lug  on  the  palatal  side,  was  finally  cemented  to  the  bicuspid  to 
anchor  the  end  of  the  spring.  The  ends  of  the  wire-clasps,  after  being 
embedded  in  the  wax  in  proper  position  for  anchorage,  were  covered 
with  plaster  to  hold  them.  The  looped  spring  across  the  centre 
and  the  spring  for  moving  the  bicuspid  had  pieces  of  binding  wire 
placed  about  them,  their  ends  projecting  upward  to  extend  into 
the  plaster,  so  as  to  hold  the  springs  when  the  upper  part  of  the  fiask 
was  made  and  separated  for  the  removal  of  the  try-plate.  The  case 
was  then  packed  with  rubber,  care  being  exercised  to  have  the  rub- 
ber extend  well  around  the  ends  of  the  springs  and  clasps. 

After  the  lateral  expansion  of  the  arch  was  somewhat  advanced, 
a  spring  was  attached  for  moving  the  front  teeth  outward.  A  platina- 
gold  collar  with  a  lug  on  the  palatal  side  was  cemented  to  each  of 
the  central  incisors.     A  spring-wire  was  then  formed  to  pass  under 


144 


EXPANSION   OF  THE   DENTAL   ARCH 


the  lugs,  following  the  palatal  curve  of  the  teeth  to  the  cuspids, 
where  the  wire  was  bent  back  on  itself  and  made  to  form  the  shape 
of  the  letter  S,  the  ends,  extending  into  holes  made  in  the  vulcanite 
on  each  side  in  such  form  that  the  spring  could  be  taken  out  when 
desired. 

The  patient  removed  the  appliance  daily  for  cleansing.  Slight 
additional  pressure  was  put  on  the  springs  by  bending  open  the 
loops  about  once  in  four  days.  «  Fig.  113  shows  the  condition  of  the 
occlusion  after  the  regulating  was  completed. 

Anterior  Expansion  of  the  Lower  Arch. — The  anterior  expansion 

of  the  lower  arch  is    not  infrequently  required  in  cases  of  arrested 

Pjq  i]^3  development  of  the  jaw, 

the  incisors  needing  to  be 
v-fcv-  .  ■..■:::^^^^s:.,.i^fJ:■y£:■:■^.::^;^.:■:m::         moved  outward  so  as  to 

give  proper  form  to  the 
arch,  or  to  make  room  for 
erupting  laterals  or  cus- 
pids. 

Fig.  114  shows  the  po- 
sition of  the  teeth  in  the 
lower  arch  of  Miss  V., 
aged  eight  years,  a  marked  case  of  arrested  anterior  development. 
The  lateral  incisors  were  considerably  inside  of  the  normal  line,  with 
the  spaces  much  too  narrow- 
for  their  admission.  An  appa- 
ratus for  the  anterior  expan- 
sion was  made  by  arranging 
spring-clasp  attachments  on  the 
second  deciduous  molars ;  the 
anchorage  portions  were  con- 
nected with  a  lingual  base- 
wire.  The  front  part  of  the 
base-wire  was  bent  downward 
as  low  as  the  tissues  would  per- 
mit without  interfering  with  the  action  of  the  tongue.  Two  curved 
finger-springs  were  attached  to  the  anchorage  w^ith  the  ends  of  the 
base-wire,  one  on  either  sid(,',  and  shaped  lo  cxtond  forward,  follow- 
ing the  lingual  curve  back  of  the  teetii  to  be  moved.  The  free  ends 
were  lelt  long  to  extend  well  over  to  the  opposite  side  of  the  arch, 


v>.r=3K;/.v.^£j%>v'/ss:-:-j:;iy^v^^^S 


Fig.  114. 


ANTERIOR   EXPANSION,  LOWER    ARCH 


145 


the  springs  parallel  with  one  another  and  retained  by  passing  under 

lugs  on   collars   cemented    to  the   laterals.     Force  was  applied  by 

slightly  bending  forward  the  fuiger-sin'ings  from  time  to  time.    Fig.  115 

illustrates  the  appliance  and  the  ,,      ,,. 

1  '  I'iG.  11;.). 

position  of  the  teeth  after  the  com- 
pletion of  the  regulating,  the  same 
appliance  being  continued  in  use 
for  retaining. 

Another  ai)paratus  of  con- 
venient form  for  anterior  expan- 
sion is  shown  in  Fig.  116.  One 
or  more  collars  with  lugs  on  the 
lingual  side  are  cemented  to  the  in- 
cisors.    Spring-clasp  attachments 

are  arranged  on  the  second  deciduous  molars  with  partial-clasps  on 
the  adjoining  teeth  ;  the  sides  are  connected  with  a  lingual  base-wire 

bent  downward  as  described, 
with  a  slight  space  left  be- 
tween it  and  the  teeth  on  the 
sides  of  the  arch  just  in  front 
of  the  anchorage  portions. 

For  the  anterior  expan- 
sion, a  spring-wire,  about 
No.  19  gauge,  is  made  to  fol- 
low the  lingual  curve  of  the 
teeth,  and  is  formed  into  a 
U-shaped  loop  about  two-  to 
three-eighths  of  an  inch  long 
on  each  side  of  the  arch,  the 
loops  being  arranged  a  little  in  front  of  the  anchorage  portion  to  which 
the  ends  are  soldered,  with  the  loops  resting  between  the  base- 
wire  and  the  tc^eth,  projecting  downward.  The  anterior  part  of  the 
base-wire,  bent  downward  in  this  manner,  makes  it  easier  for  the 
operator  to  open  tlie  loops  in  the  spring-wire  in  order  to  cause  the  de- 
sired pressure,  and  interferes  less  with  the  action  of  the  tongue.  After 
the  arch  has  been  expanded  anteriorly,  if  desired,  the  sides  of  the  base- 
wire  and  spring  can  be  bent  outward  for  the  lateral  expansion  of  the 
arch.  A  single  loop  in  the  spring  arranged  at  the  median  line  is  some- 
times applicable  for  moving  outward  instanding  lateral  incisors. 

10 


146 


EXPANSION  OF  THE  DENTAL  ARCH 


A  method  employed  for  expanding  the  lower  arch  anteriorly 
and  laterally  with  springs  attached  in  vulcanite  is  illustrated  in 
Fig.  117. 

The    arch   was    much    contracted,   and 
erupted  far  back  of  their  normal  position. 


Fig.  117. 


the  lateral  incisors  had 
The  space  for  the  lateral 
on  the  right  side  was 
nearly  closed,  W'hile  on 
the  left  side  it  was  much 
too  narrow.  An  accu- 
rate model  was  prepared 
and  an  appliance  made 
of  vulcanite,  arranged  in 
lateral  halves,  one  on 
each  side  of  the  arch, 
and  connected  by  a 
spring  base-wire.  The 
centre  of  the  base-wire 
was  formed  into  a  loop 
to  rest  between  the  instanding  lateral  incisors  and  near  the  gum 
back  of  the  centrals,  with  the  ends  extending  into  the  rubber.  The 
parts  of  the  appliance  on  each  side  were  anchored  to  the  teeth  by  a 
continuous  spring-clasp,  which  was  made  by  extending  a  platino- 
iridium  wire  from  the  rubber  over  ttie  arch  at  the  junction  of  the 
second  deciduous  and  first  permanent  molars,  across  the  buccal  side 
of  the  deciduous  molars  and  cuspid  near  the  gum,  and  through  the 
space  in  front  of  the  cuspid  to  the  lingual  side,  w^here  it  was  attached 
to  the  rubber  again. 

The  continuous  spring-clasps  anchor  the  appliance,  prevent  it  from 
pressing  unduly  on  the  gum,  and  do  away  with  the  necessity  of 
extending  the  rubber  on  to  the  grinding  surface  of  the  teeth,  which 
would  interfere  with  the  articulation. 

The  loop  in  the  spring  base-wire  was  opened  from  time  to  time 
by  bending.  This  expanded  the  anterior  part  of  the  arch  laterally 
and  made  room  for  the  lateral  incisors  to  take  their  positions. 

The  lateral  incisors  were  moved  outward  by  attaching  spring- 
wires  in  the  rubber,  each  extending  forward  in  a  curve  to  the  lingual 
surface  of  the  lateral  on  the  opposite  side.  A  more  detailed  descrip- 
tion of  this  case,  including  the  method  of  retaining,  is  given  on 
page  164. 


ANTERIOR  EXPANSION,  UPPER  ARCH 


147 


The  advantage  of  this  form  of  appliance,  and  especially  of  the 
clasj)  portion  and  looped  spring  base-wire,  was  described  in  a  paper 
read  before  the  New-  York  Odontological  Society  in  1887.* 

A  metal  device  for  causing  anterior  and  lateral  expansion  of  the 
arch  is  readily  made  by  attaching  curved  fmger-springs  to  an  appli- 
ance like  Fig.  85. 

In  some  conditions  for  anterior  expansion  of  the  lower  arch  sup- 
plemental force  is  used  to  advantage.     (See  Fig.  144.) 

Anterior  Expansion  of  the  Upper  Arch. — The  application  of  force 
to  the  upper  incisors  and  cuspids  for  causing  their  outward  move- 
ment is  usually  also  sufficient  to  move  forward  the  alveolar  process 
that  surrounds  them,  and  in  young  patients,  when  the  force  is  applied 
gradually,  it  not  uncommonly  forces  forward  the  process  and  at  the 
same  time  the  bone  of  the  intermaxillary  region. 

Fig.  118  shows  a  suitable  appliance  for  expanding  the  anterior 
third  of   tlie  arcli.      It   is   constructed  with    a    palatine    base-wire 

Fig.  118. 


anchored  wath  partial-clasps  and  spring-clasp  attachments.  A  curved 
finger-spring  is  made  to  extend  forward  from  each  of  the  anchorage 
portions,  following  the  gum  line  on  the  lingual  side  of  the  teeth, 
usually  reaching  to  the  opposite  side  of  the  arch.  For  retaining  the 
ends  of  the  springs,  a  collar  with  a  lug  is  cemented  to  each  of  the 
laterals,  central  incisors,  or  cuspids. 


*  Jackson,  Dental  Cosmos,  1887,  p.  376. 


148 


EXPANSION  OF  THE  DENTAL  ARCH 


Fig.  119. 


Force  is  applied  to  the  teeth  to  be  moved  by  bending  outward  the 
corresponding  part  of  the  springs. 

Fig.  119  illustrates  a  combination  expansion  device  for  expanding 
the  arch  anteriorly,  and  also  laterally  when  desirable.     For  lateral  ex- 
pansion, a  palatine  base- 
wire    crosses    the    distal 
part  of  the  arch,  the  ends 
extending  forward  to  be 
attached  in  the  anchorage. 
For   the    anterior    move- 
ment,    a     semi- circular 
spring  is  fitted  to  the  lin- 
gual side    of  the   incisors 
near  the  gum,  passing  un- 
derneath lugs   on  collars 
cemented  to  two  or  more 
of   them,   beyond    which 
two  U-shaped   loops    are 
formed  projecting  well  to- 
wards the  median  line,  with  the  ends  of  the  spring  attached  in  the 
anchorage.     Action  is  caused  by  opening  the  loops  a  little  at  a  time. 
An  apparatus,  consisting  of  a  modified  Coffin  plate  and  springs, 

for  forcing  outward  the  in- 

•n     +V.      K  1  Fig.  120. 

cisors  wjth   the  bone   and 

process  of  the  iatermaxil- 
lary  region  is  shown  in  Fig. 
120.  It  is  made  of  vul- 
canite covering  the  palatine 
arch,  with  the  anterior  part 
separated  approximately  at 
a  right  angle  with  the  me- 
dian line  opposite  the  cus- 
pids, leaving  it  similar  to 
the  shape  of  the  palatine 
outline  of  the  intermaxil- 
lary bone.  This  is  con- 
nected to  the  body  of  the 
plate  with  two  springs  of  about  No.  18  gauge  formed  into  loops. 
The  body  of  the  plate  is  retained  by  wire-clasps  or  spring-clasps  ex- 


ANTEKIOR   EXPANSION,  UPPER  ARCH  149 

tending  around  a  molar  and  bicus{)id  on  each  side,  witli  the  anterior 
part  retained  by  lugs  on  collars  cemented  to  the  teeth  to  be  moved. 

For  the  unequal  spreading  of  the  maxilla,  see  Fig.  199. 

Where  the  whole  arch  is  contracted,  it  often  occurs  that  the 
front  teeth  need  to  be  moved  considerably  outward.  Generally,  in 
such  cases,  if  much  force  is  to  be  exerted,  the  operation  for  the 
lateral  expansion  should  not  be  undertaken  until  the  teeth  in  the 
front  of  the  arch  have  been  moved  outward  into  line,  as  usually  it  is 
not  practicable  to  utilize  teeth  for  anchorage  that  have  been  moved. 
For  these  conditions,  the  apparatus  for  moving  outward  the  upper 
incisors  can  be  made  with  any  desired  form  of  spring  attached  in  a 
plate,  or  with  a  rigid  i)alatine  base-wire.  When  ready  to  expand  the 
arch  laterally,  the  rigid  base-wire  can  be  separated  in  the  centre  and 
converted  into  a  spring  base-wire.  (See  Figs.  369-371.)  This 
change  is  easily  made,  as  described  in  Chapter  VII.,  Anchorage  and 
Appliances,  page  83. 

For  description  of  other  apparatus  for  anterior  expansion,  the 
reader  is  referred  to  Chapter  XL,  Incisors,  to  move  Outward  or 
Labially,  including  supplemental  force  (Fig.  373). 


CHAPTER  X 


CONTRACTION  OF  THE  DENTAL  ARCH 


Of  the  cases  of  irregularity  presented,  but  a  small  percentage 
require  the  lateral  contraction  of  the  distal  part  of  the  arch,  but 
occasionally  the  occlusion  can  be  improved  by  moving  the  molars 
lingually  (Fig.  482).  The  incisors,  cuspids,  and  bicuspids  are  more 
frequently  too  prominent,  and  need  to  be  moved  inward  to  improve 
the  occlusion  and  contour. 

Contraction  of  the  Lower  Arch. — Fig. 
before  regulation,  of  the  teeth  of  Miss  S., 
nervous  temperament. 

Fig.  121. 


121  shows  the  position, 
aged  fourteen  years  ;  of 


The  right  lower  cuspid,  left  lower  lateral  incisor,  cuspid,  and  first 
bicuspid  closed  outside  of  the  teeth  of  the  upper  arch,  with  slight 
spaces  between  some  of  them,  causing  an  unpleasant  expression  of 
the  mouth.  This  form  of  irregularity  is  not  commonly  met  with, 
and  is  considered  difficult  to  correct  with  ordinary  appliances. 

Fig.  122  shows  the  form  of  device  used.  A  stiff  lingual  base- 
wire  was  arranged  to  follow  the  inner  curve  of  the  arch,  leaving 
sufficient  space  between  it  and  the  irregular  teeth  to  allow  them  to 
be  moved  into  position.  Tlie  ends  of  the  base-wire  were  anchored 
to  the  first  molars  by  sjiring-clasp  atlachmcMits.  Wire-clasps  bent 
to  extend  to  tlio  distal  side  of  the  second  molars  to  assist  the  an- 
^rJO 


CONTRACTION  OF  THE  LOWER  ARCH 


151 


chorage  were  soldered  to  the  partial-clasps  at    the  same  time  the 

base-wire  was  attached. 

Fig.  122. 


The  right  lower  cuspid  was  moved  into  line  by  a  spring  shaped 
similar  to  a  spring-clasp,  made  by  bending  a  small-sized  spring-wire 
twice  at  right  angles,  having  the  width  between  the  parallel  sides  equal 
to  the  width  of  the  cuspid.  This  portion  of  the  spring  was  attached 
to  the  base-wire,  and  the  arms  bent  to  extend  up  and  over  the  arch 
at  the  junction  of  the  teeth  either  side  of  the  cuspid  to  the  gum  hue, 
the  ends  being  curved  towards  one  another  to  rest  on  the  labial  side 
of  the  tooth,  leaving  the  ends  free. 

The  left  lower  lateral,  cuspid,  and  first  bicuspid  were  moved  into 
position  by  a  continuous  spring,  shaped  to  cross  their  labio-buccal  faces 

Fig.  123. 


at  the  gum  line.     The  ends  of  the  spring  extended  over  the  arch  at  the 

junction  with  the  adjoining  teeth,  and  were  soldered  to  the  base-wire. 

Force  was  exerted  by  removing  the  appliance  and  bending  the 

springs  a  little  at  a  time  to  rest   nearer  the  base-wire.      Fig.  123 


152 


CONTRACTION  OF  THE  DENTAL  ARCH 


Fig.  124. 


illustrates  the  position  of  the  teeth  when  the  regulation  was  com- 
pleted, the  same  appliance  being  used  for  retaining  them. 

Many  similar  forms 
of  apparatus  have 
been  devised  for  con- 
tracting different  parts 
of  the  arch.  Fig.  124 
shows  an  appliance 
employed  for  con- 
tracting the  anterior 
part  of  the  arch  by 
moving  inward  the 
lower  incisors.  A  lin- 
gual base -wire  was 
anchored  by  spring- 
clasp  attachments  to 
the  molars  and  par- 
tial-clasps on  the  cuspids.  A  spring-wire,  No.  19  guage,  was  shaped 
to  follow  the  labial  side  of  the  incisors  a  little  above  the  centre  of 
their  crowns.  Near  the  cuspids  the  wire  was  curved  downward 
towards  the  gum,  and  again  upward,  forming  U-shaped  loops.  The 
ends  were  then  curved  backward  to  extend  over  the  arch,  passing 
near  the  incisive  edge,  to  the  Fig.  125. 

lingual  side,  where  they  were 
united  with  solder  to  the 
partial-clasps  at  id  base- wire. 
Figure  125  illustrates  the  ap- 
pearance of  the  appliance. 
Force  on  the  incisors  was 
caused  by  the  labial  spring, 
bending  inward  the  inner  lialf 
of  each  of  the  loops  with  llat- 
nosed  pliers. 

Contraction  of  the  Upper  Arch. — Cases  are  not  infrequently  pre- 
sented with  spaces  between  the  teeth  and  an  abnormal  enlargement 
of  the  arch,  resulting  from  hypertrophy  or  chronic  congestion  of  the 
tongue.  These  conditions  are  acconipwnicd  willi  irritation  of  the 
digestive'  tra<-t.  In  some  ca.ses  of  nervous  irritation  the  tongue  is 
thrust  forcibly  forward,  causing  excessive  pressure  on  the  teeth  of 


CONTRACTION   OF  THE   TIPPER   ARCH  153 

the  anterior  arc.li.  Usually  there  are  markings  or  fleep  indentations 
on  the  tip  or  lateral  margins  of  the  tongue,  caused  by  its  pressure 
against  the  teeth.  If  the  physical  condition  be  not  corrected,  the 
teeth  Avhen  regulated  will  iiccil  to  be  retained  by  a  device  worn 
regularly  at  night. 

The  form  of  appliance  presented  in  Fig.  12(3  is  designed  to  con- 
tract the  arch  laterally,  and,  if  desired,  at  the  same  time  to  move  the 

Fig.  126. 


front  teeth  into  line,  closing  the  spaces.  It  can  be  used  for  either 
the  upper  or  lower  arch.  The  device  is  made  by  forming  a  spring 
base- wire  to  the  palatal  curve,  leaving  a  space  about  one-eighth  of  an 
inch  between  it  and  the  necks  of  the  incisors  and  cuspids.  The  ends 
of  the  base-wire  are  anchored  by  forming  partial-clasps  to  the  molars 
and  bicuspids  that  are  to  be  moved,  and  extending  a  continuous 
spring-clasp  on  the  buccal  side  of  the  teeth  near  the  gum,  with  one 
end  passing  over  the  arch  at  the  mesial  side  of  the  first  bicuspid,  to 
be  soldered  to  tlie  partial-clasp  with  the  base-wire.  The  other  end, 
extending  over  the  arch  at  the  junction  of  the  molars,  is  to  be 
attached  to  the  partial-clasp  in  the  distal  part  of  the  arch.  A  semi- 
circular spring,  with  two  U-shaped  loops  for  moving  the  incisors 
and  cuspids  inward,  is  formed  to  cross  the  incisors  at  the  gum  line, 
with  the  loops  located  opposite  the  cuspids,  pointing  upward  to  fol- 
low the  contour  of  the  gum  so  as  not  to  interfere  with  the  action  of 
the  lip.    The  ends  are  to  be  soldered  to  the  continuous  spring-clasps. 

The  arch  is  contracted  laterally  by  removing  the  appliance  and 
bending  the  ends  of  the  spring  base-wire  towards  each  other. 

Force  is  applied  on  the  fronts  of  the  incisors  and  cuspids  by  closing 
the  loops  somewhat  in  the  spring  that  crosses  them. 


154 


CONTRACTION  OF  THE  DENTAL  ARCH 


To  systematize  the  bending  of  the  springs,  a  tracing  is  made  by 
laying  the  appliance  on  a  piece  of  card-board  and  marking  its  out- 
lines with  a  sharp-pointed  pencil.  A  mark  is  to  be  made,  inside  of 
the  original  tracing,  for  the  distance  it  is  desired  to  change  the  springs, 
and  the  wires  then  bent  to  compare  with  the  new  marking. 

In  Fig.  127  is  seen  an  appliance  for  contracting  the  anterior  part 
of  the  upper  or  lower  arch  when   there  are  spaces  between  the 


Fig.  127. 


teeth.  It  is  applicable  in  cases  of  close  occlusion.  The  device  is 
made  by  forming  a  spring-clasp  attachment  over  one  or  more  molars 
or  bicuspids  on  each  side  of  the  arch  for  anchorage,  with  the  par- 
tial-clasps arranged  on  the  buccal  side,  and  shaping  a  labio-buccal 
spring  base-wire,  about  No.  19  gauge,  to  cross  the  front  teeth, 
following  the  line  of  the  gum  to  the  first  bicuspids.  Here  one  or 
more  loops  or  corrugations  are  formed  in  the  wire  on  each  side 
of  the  arch,  the  ends  of  the  wire  extending  back  to  the  anchor- 
ages to  which  they  are  soldered.  The  loops  should  be  shaped 
to  the  contour  of  the  gum  so  as  not  to  interfere  with  the  action  of 
the  lip.  The  spring  is  held  in  position  on  the  incisors,  by  forming  a 
thin  piece  of  plate-metal  to  the  labial  side  of  one  or  more  of  them, 
with  one  end  made  to  extend  over  the  incisive  edge  and  the  other 
passing  under  the  spring  to  which  it  is  soldered.  By  removing  the 
appliance  and  closing  the  loops  somewhat,  the  teeth  are  forced 
inward,  which  in  effect  contracts  the  size  of  tlie  arch. 

When  u.sed  for  the  upper  arch,  and  when  the  occlusion  will  permit, 
the  appliance  will  be  more  firmly  retained  by  reversing  the  spring- 


CONTRACTION   OF  THE  UPPER  ARCH  155 

clasp  attachments,  having  the  partial-clasps  on  the  palatal  side,  and 
the  anchorage  portions  connected  with  a  palatine  base-wire.  In  such 
case  the  spring-wire  should  be  shaped  to  extend  over  the  arch  at  the 
junction  of  two  of  the  teeth  to  the  lingual  side,  where  the  ends 
should  be  attached  to  the  base-wire. 

The  contraction  of  the  arch  laterally  in  the  region  of  the  bicuspids 
and  molars  has  been  accomplished  with  a  device  as  shown  in  Fig.  465. 

In  the  early  eruption  of  the  teeth  it  is  occasionally  desirable  to 
lessen  the  prominence  in  the  anterior  part  of  the  arch,  especially 
when  there  are  spaces  between  the  teeth.  A  retainer  should  be 
worn  for  a  considerable  length  of  time  to  prevent  over-develop- 
ment. Other  methods  of  contracting  the  anterior  part  of  the  arch 
by  moving  the  teeth  lingually  will  be  considered  in  Chapter  XII., 
Incisors,  to  move  Inward  or  Lingually. 


CHAPTER  XI 
INCISORS,    TO    MOVE    OUTWARD    OR    LABIALLY 

Methods  of  correcting  the  position  of  incisors  that  are  inside  of 
the  natural  circle  of  the  arch  and  need  to  be  more  prominent  will 
now  be  considered,  first  describing  the  outward  or  labial  movement 
of  the  lower  incisors. 

The  difficulty  experienced  in  regulating  the  teeth  of  the  lower  arch  by 
the  ordinary  methods  recommended  often  prompts  the  dentist  to  delay 
the  operation  from  time  to  time,  and  more  often  even  its  consideration. 

The  lower  incisors  are  erupted  usually  before  the  upper  ones. 
When  normally  located  they  assist  in  guiding  the  upper  incisors  into 
a  correct  circle  as  the  latter  move  downward  in  the  process  of  erup- 
tion. When  the  lower  incisors  have  taken  an  irregular  position,  the 
upper  incisors  generally  assume  an  irregular  position  also.  For  this 
reason,  if  the  permanent  upper  incisors  are  erupting,  and  the  lower 
incisors  are  back  of  their  normal  circle,  an  appliance  should  be  in- 
serted to  cause  their  outward  movement,  encouraging  the  development 
of  the  bone  and  process ;  and  when  the  teeth  are  in  a  correct  posi- 
tion they  should  be  retained  for  a  considerable  length  of  time,  or 
until  the  upper  incisors  are  fully  erupted.  If  the  lower  jaw  is  not 
developing  as  rapidly  as  the  upper,  pressure  outward  on  the  lower 
incisors  will  encourage  its  anterior  development. 

The  permanent  incisors  may  take  an  abnormal  position  from  want 
of  space  caused  by  lack  of  development  of  the  jaw.  When  the 
lower  incisors  are  in  good  position  and  the  upper  incisors  irregular, 
it  is  not  always  advisable  to  enlarge  the  anterior  upper  arch,  prior  to 
the  loss  of  the  deciduous  molars,  enough  to  admit  the  irregular 
teeth.  The  molars  occupy  more  space  than  is  required  for  the  in- 
coming bicuspids,  and  when  the  deciduous  molars  are  lost  the  decid- 
uous cuspids  are  permitted  to  move  laterally  backward,  allowing 
more  space  for  the  incisors  to  take  a  correct  position  ;  and  although 
the  permanent  incisors  are  broader  than  the  deciduous  ones,  the 
permanent  cuspids  when  erupted  usually  have  room  to  take  a  good 
position  if  the  deciduous  cuspids  are  retained  until  about  the  time 
of  the  eruption  of  the  permanent  ones. 

166 


LOWER  INCISOJJS,  TO   MOVE  OUTWARD 


157 


Fig.  128. 


rmiiiiiiiia  _ 


Lower  Incisors,  to  move  Outward. — When  tlie  lower  incisors  are 
irregular  tliey  are  nsually  much  crowded  in  the  arch,  and  expansion 
is  required  to  give  llieni  a  normal  position.  Fig.  128  illustrates  a 
simple  device  for  increasing  the  space  and  moving  outward  an  in- 
standing  central  or  lateral  incisor. 

A  thin,  broad  collar  is  fitted  to  the 
tooth,  to  which  it  is  finally  cemented. 
A  piece  of  plate-metal,  a  little 
narrower  tlian  the  width  of  the 
collar,  is  swaged  with  a  form  and 
soldered  to  the  front,  making  ap- 
proximately a  box-shaped  opening, 
the  opening  being  a  little  broader 
towards  the  gum,  and  just  large 
enough  to  admit  a  loop  of  small- 
sized  spring-wire  when  bent  rather  closely  upon  itself.  The  ends  of 
the  spring  are  shaped  to  project  downward  and  outward  at  a  right 
angle  to  rest  on  the  labial  faces  of  the  adjoining  teeth.  Force  for 
moving  the  tooth  is  caused  by  bending  the  ends  of  the  spring  back- 
ward slightly  from  time  to  time  and  pressing  the  loop  portion  to  place. 
In  this  and  other  similar  devices  described  the  force  depends  upon 
the  twist  of  the  spring. 

When  desired,  instead  of  the  loop-shaped  spring,  a  narrow 
piece  of  plate-metal  can  be  soldered  to  a  wire-spring,  as  seen  at  a, 
the  metal  being  of  suitable  Avidth  to  fit  tightly  into  the  opening  on 
the  collar. 

A  device  for  moving  outward  or  inward  an  irregular  incisor  is 

made  as  illustrated  in  Fig.  129.     It  was  utilized  to  good  advantage 

Pjq  J29  to  regulate  an  instanding  left  lower 

lateral    incisor    for    Miss    E.,    aged 

twenty-three  years. 
To    the    tooth    to 

cemented 


be    moved    is 

a   collar   having  attached 

two    small    perpendicular    tubes,   a 

little  shorter  tlian  the  width  of  the 

"'"-  '  collar,  each  for  retaining  the  end  of 

a  spring.     When  the  tooth  is  to  be  moved  outward  one  of  the  tubes 

should  be  located  near  the  labio-distal,  and  the  other  near  the  labio- 


mesial  surface.     Each  spring  is  formed  into  a  loop  with  parallel  arms. 


158  INCISORS 

one  shorter  than  the  other,  the  width  of  the  loop  bemg  equal  to  the 
length  of  the  tube.  The  shorter  arm  of  the  spring  is  then  bent  at  a 
right  angle  towards  the  other  arm  to  enter  one  of  the  tubes,  usually 
from  above  downward,  and  the  longer  arm  shaped  to  rest  on  the 
labial  surface  of  the  adjoining  tooth.  Force  is  supplied  by  bending 
fonvard  the  shorter  arm  of  the  spring  and  springing  it  backward  to 
enter  the  tube.  When  both  springs  are  adjusted  the  end  of  the 
loops  should  rest  near  in  contact  at  the  centre  of  the  tooth.  If  the 
tooth  is  to  be  moved  inward,  the  tubes  should  be  attached  to  the 
lingual  side  of  the  collar. 

In  Fig.  130  is  shown  another  form  of  device  for  moving  an  in- 
cisor outward.      A  broad   collar  with  a  short  tube  soldered  per- 

FiG.  130. 


pendicularly  to  the  labial  side  near  the  centre  is  cemented  to  the 
tooth  to  be  moved.  A  small  spring  wire  is  bent  into  the  form  of  a 
U-shaped  loop,  with  the  width  between  the  parallel  arms  equal  to 
the  length  of  the  tube.  One  arm  is  left  short  and  bent  at  a  right 
angle  towards  the  other  to  enter  the  tube,  usually  from  above  down- 
ward. The  loop  is  left  sufficiently  long  to  project  well  on  to  the 
adjoining  tooth  on  one  side  when  in  position,  and  the  longer  arm 
shaped  to  extend  across  one  or  more  teeth  on  the  other  side  of  the 
tooth  being  moved.  Force  is  applied  by  bending  outward  the  shorter 
arm  of  the  spring,  and  in  adjusting  it  is  pressed  backward  to  enter 
the  tube. 

The  devices  described  are  utilized  for  moving  outward  or  inward 
the  incisors  or  other  teeth  of  the  arch,  and  also  for  their  rotation. 

An  appliance  Avitli  a  spring,  termed  a  finger-spring,  is  used  more 
often  than  any  other  for  moving  central  or  lateral  incisors  of  either 
the  upper  or  lower  arch. 

For  moving  lowc-r  incisors  outward  an  appliance  is  made  with 
a  lingual  base-wire,  about  No.  14  gauge,  formed  at  the  gum  line, 


LOWER   INCLSORS,  TO  MOVE  OUTWARD 


159 


extending  backward  on  either  side,  the  ends  anchored  with  spring- 
clasp  attachments  to  the  deciduous  molars,  bicuspids,  or  permanent 
molars,  the  wire  of  the  spring-clasp  being  of  No.  20  or  21  gauge  (Fig. 
131).     A  finger-spring,  about  No.   18  gauge,  bent  into  a  curve,  is 


Fig.  131. 


attached  to  the  partial-clasp  or  base-wire  near  the  anchorage  portion, 
in  position  to  extend  forward  and  to  the  opposite  side,  crossing  the 
teeth  to  be  moved.  The  free  end  of  the  spring  is  held  in  position 
with  a  lug  and  collar  cemented  to  one  or  more  of  the  incisors. 

Force  is  applied  by  bending  the  spring  outward  slightly  from  the 
base-wire.  Owing  to  the  length  of  the  spring  it  continues  its  action 
for  several  days,  and  therefore  it  is  not  necessary  to  see  the  patient 
oftener  than  once  or  twice  a  week,  or  perhaps  three  times  in  two 
weeks,  the  appliance  being  removed  daily  for  cleansing. 

When  one  of  the  incisors  has  taken  a  position  back  of  the  natural 
circle  of  the  arch,  with  the  space  too  narrow  for  its  admission, 
simple  pressure  on  the  lingual 
side  is  usually  sufficient  for 
moving  it  outward.  In  Fig.  132 
is  shown  a  device  with  the  finger- 
spring  curved  forward,  the  end 
being  held  to  the  irregular  incisor 
by  a  lug  on  a  collar. 

When  the  space  is  mucli  too 
narrow,  and  no  provision  has 
been  made  for  separating  the 
adjoining  teeth  laterally,  they  are 

likely  to  be  driven  outward  by  force  applied  to  the  irregular  tooth  and 
to  assume  irregular  positions.     This  can  generally  be  avoided,  and 


Fig.  132. 


160 


INCISORS 


space  made  for  the  admission  of  tlie  incisor,  by  attaching  an  additional 
spring  to  the  end  of  the  finger-spring  (Fig.  133).  A  small  spring- 
wire  is  bent  twice  at  right  angles,  the  width  between  the  parallel  sides 
being  equal  to  the  width  of  the  tooth  to  be  moved,  and  attached 
jTj^^  ;i33  with    solder   to    the    finger- 

spring,  one  end  on  either 
side  being  shaped  to  curve 
upward  to  the  incisive  edge 
and  to  pass  over  the  arch  to 
the  gum  line,  Avhere  the  ends 
are  curved  outward  to  rest 
on  the  labial  side  of  the  ad- 
joining teeth. 

The  action  of  the  spring 
is  caused  by  separating  the 
lateral  sides  by  bending, 
gradually  increasing  the  space,  while  by  bending  the  ends  of  the 
spring  backward  towards  the  finger-spring,  pressure  is  exerted  on 
the  labial  side  of  the  adjoining  teeth,  assisting  the  finger-spring  in 
moving  the  incisor  into  the  circle.  If  required,  a  thin  collar  with  a 
lug  on  the  lingual  side  may  be  cemented  to  the  incisor  for  retaining 
this  part  of  the  appliance,  when  it  can  be  used  independently  or  in 
connection  with  the  finger-spring. 

Cases  are  frequently  pre-  Fig.  134. 

sented  with  both  of  the 
lower  or  upper  lateral  in- 
cisors erupted  inside  of  the 
proper  line  and  consider- 
ably back  .of  the  fine  of 
the  central  incisors.  Their 
position  should  be  corrected 
early  (Fig.  134). 

An  appliance  is  made 
with  a  lingua]  base-wire, 
anchored  witli  partial  clasps 

and  spring-clasp  attachments  to  the  deciduous  or  permanent  teetli. 
The  base-wire  should  be  bent  at  an  obtuse  angle  downward  and 
forward  just  in  front  of  the  anchorage  portion,  leaving  a  space  be- 
tween it  and  the  gum,  and  extonrlod  around  the  fi-ont  part  of  the 


LOWER  INCISORS,  TO  MOVE  OUTWARD  161 

arch  as  low  as  the  tissues  will  permit  without  interfering  with  the 
action  of  the  tongue.  A  spring-wire,  about  No.  19  gauge,  is  formed 
in  a  curve  to  cross  the  lingual  side  of  the  incisors,  with  a  U-shaped 
loop  about  one-fourth  of  an  inch  long  formed  in  the  wire  on  either 
side  opposite  the  deciduous  molars  or  first  bicuspids,  to  rest  in  the 
space  between  the  base-wire  and  the  gum.  The  ends  of  the  spring 
are  soldered  to  the  partial-clasps  with  the  base-wire.  The  anterior 
part  of  tlie  spring  is  retained  with  lugs  on  collars  cemented  to  the 
irregular  teeth.  Force  for  moving  the  laterals  outward  is  applied  by 
opening  the  loops  or  corrugations  of  the  spring  slightly,  from  time 
to  time,  with  round-nosed  pliers. 

Fig.  135  illustrates  the  case  of  Master  S.,  eight  years  of  .age.     The 
permanent  lower  incisors  were  erupted  in  an  irregular  position  and 

Fig.  135. 


considerably  back  of  the  upper  ones,  which  were  also  irregular  and 
recjuired  to  be  moved  outward.  An  appliance  for  their  correction 
was  made  by  forming  a  lingual  base-wire  to  the  inner  curve  of  the 
arch,  with  the  anterior  portion  of  it  bent  downward  to  rest  consid- 
erably below  the  necks  of  the  teeth,  making  it  more  convenient  for 
manipulation.  The  ends  were  anchored  by  spring-clasp  attach- 
ments over  the  second  deciduous  molars,  with  partial-clasps  on  the 
adjoining  teeth.  A  spring  wire  was  then  soldered  to  the  base-wire 
near  the  anchorage  portion  and  shaped  to  extend  forward  to  cross 
the  lingual  side  of  the  incisors.  A  collar  with  a  lug  was  cemented 
to  one  of  the  laterals  to  hold  the  end  of  the  spring  in  position.  The 
incisors  were  gradually  moved  outward  by  bending  the  spring  wire 
slightly  at  a  time.     When  required,  a  longer  spring  was  added  to 

11 


102 


INCISORS 


Fig.  136. 


follow  their  movement  (Fig.  13G).  The  base-wire  did  not  interfere 
with  tlie  action  of  tlie  tongae,  and  was  not  changed.  As  the  lo\Yer 
incisors  were  moved  outward  they  exerted  force  on  the  lingual  side 
of  the  upper  incisors,  moving  them  outward  to  proper  position.    Tlie 

same  appliance  was  worn  several 
months  as  a  retainer  until  the 
teeth  became  firm  in  the  process. 
Fig.  137  represents  the  posi- 
tion of  the  teeth  and  the  ap- 
pliance used  for  their  correction 
in  the  case  of  Miss  K.,  aged  eight 
years.  The  lateral  incisors  were 
erupted  considerably  back  of  the 
centrals,  with  insufficient  space 
for  them,  requiring  that  the  circle 
of  the  arch  be  enlarged,  moving 
outward  all  of  the  incisors  and  the  deciduous  cuspids.  The  upper 
incisors  Avere  also  irregular,  and  needed  to  be  moved  outward.  The 
appliance  was  made  by  forming  a  lingual  base-wire  to  follow  the 
curve  of  the  arch,  having  the  front  part  bent  considerably  downward, 
and  placed  as  low  as  could  be  without  interfering  with  the  action  of 


^\- 


the  tongue.  The  ends  were  anchored  with  spring-clasp  attaeliiuenls 
over  the  second  deciduous  molars.  II  is  usually  an  advantage  to 
have  partial -clasps  on  one  or  more  of  the  adjoining  teeth.  Two 
curved  finger-springs  were  attached,  one  on  either  side,  to  the  euds 
of  the  bas(,'-wire,  each  extending  forward  In  llie  opposite  side  of  Hie 
arch,  where  they  rested  on  the  lingual  snrface  of  the  irregular  teeth, 
one  of  them  passing  just  below  the  other.    The  springs  were  retained 


LOWER  INCISORS,  TO  MOVE  OUTWARD 


163 


in  position  with  lugs  on  collars  cemented  to  the  lateral  incisors. 
Force  was  applied  by  ])ending  the  ends  of  the  spring  outward,  gradu- 
ally moving  the  teeth  into  proper  position  (Fig.  138).  The  same 
appliance  completed  the  operation,  which  was  done  in  about  three 
montlis.  The  upper  incisors  were 
moved  outward  by  the  action  of 
the  lower  ones  against  them  in 
occlusion. 

The  upper  incisors  cannot 
always  be  moved  in  this  manner 
without  endangering  the  articu- 
lation or  lap,  and  should  not  be 
attempted  if  the  teeth  have  become 
firm  in  their  sockets.  It  can  be 
depended  on  only  soon  after  their 
eruption,  and  in  cases  where  the  teeth  of  the  upper  arch  lap  well  over 
those  of  the  lower.  Where  an  even  expansion  of  tlie  anterior  part 
of  the  arch  is  required  there  is  an  advantage  in  having  two  springs 
extending  forward,  as  they  can  be  bent  so  as  to  exert  force  on  any 
particular  tooth,  or  to  move  all  of  them  outward  at  the  same  time. 

Fig.  139  shows  an  appliance  for  enlarging  the  circle  of  the  arch, 
at  the  same  time  movhig  outward  the  incisors.    In  the  case  illustrated 

the  cuspids  were  too  promi- 
nent, with  insufficient  space 
for  them.  The  arch  was  ex- 
panded laterally  with  a  lin- 
gual spring  base-wire,  No.  14 
gauge,  having  in  it,  at  the 
median  line,  a  U-shaped  loop 
about  one-fourth  of  an  inch 
long  pointing  downward,  the 
ends  of  the  base-wire  extend- 
ing backward  and  soldered  to 
the  spring-clasp  attachments 
for  anchorage.  The  anterior  part  of  the  arch  was  expanded  by  two 
finger-springs.  No.  19  gauge,  attached  one  on  either  side  with  the 
base-wire.  They  extended  forward,  following  the  lingual  curve,  pass- 
ing one  another,  with  the  free  ends  resting  on  the  opposite  side.  The 
front  of  the  appliance  was  retained  by  cementing  to  each  of  the 


Fig.  139. 


164 


INCISORS 


Fig.  140. 


lateral  incisors  a  collar  with  a  lug.     Force  was  applied  by  making 
slight  changes  in  the  shape  of  the  springs  from  time  to  time. 

In  cases  where  the  arch  is  to  be  much  expanded  the  springs  should 
be  left  long,  otherwise  they  will  need  to  be  replaced  with  longer  ones 
as   the  teeth  are  moved   outward.      The   combined  action   of  the 

springs  arranged  in  this 
manner  assists  the  base- 
wire  in  expanding  the 
arch  laterally. 

Fig.  140  illustrates  an- 
other form  of  device  with 
a  lingual  base-wire,  for 
expanding  the  arch  lat- 
erally and  moving  out- 
ward instanding  lower 
incisors.  The  base-wire 
is  arranged  to  follow  the 
inner  curve  of  the  arch, 
resting  as  low  as  the 
tissues  will  permit ;  the  ends  are  bent  upward  to  be  soldered  to  the 
centre  of  the  anchorage  portions,  which  include  the  cuspids,  bicus- 
pids, and  molars.  To  the  anterior  part  of  the  anchorage  are  attached 
two  curved  finger-springs,  one  on  either  side  to  pass  back  of  the 
incisors.  This  connection  of 
the  base-wire  to  the  centre  of 
the  anchorage  prevents  any 
warping  of  the  appliance  as  the 
ends  are  bent  outward  for 
causing  pressure. 

Fig.  141  shows  the  cast  of 
the  teeth  of  a  boy  aged  nine 
years,  with  the  lower  arch  much 
too  narrow,  each  of  the  lat- 
eral incisors  having  erupted  far 
back  of  the  projx'r  line.*  The 
space  for  the  lateral  on  the  right  was  nearly  closed,  while  on  the 
left  it  needed  to  be  broadened  nearly  11  ic  half  of  the  width  of  the 


*  Jackson,  Dental  Cosmos,  1887,  p.  375. 


LOWER  INCISORS,  TO  MOVE  OUTWARD 


165 


tooth.  The  docirhious  molars,  cuspids,  and  first  permanent  molars 
were  in  symmetrical  line.  For  expanding  tlie  arch  and  making  room 
for  the  laterals  a  vulcanite  plate  was  made  in  two  parts,  arranged  on 
the  lingual  side  of  the  deciduous  and  permanent  molars,  extending  a 
little  over  the  gum.  The  latter  is  not  often  required  (see  page  123). 
The  two  sides  were  connected  with  a  spring  base-wire,  No.  14  gauge, 
formed  in  a  loop  to  rest  between  tlic  laterals  near  the  gum  back  of 
the  central  incisors,  with  the  ends  extending  into  the  rubber  on  either 
side.  (This  form  of  plate  can  be  made  of  cast  metal  in  place  of  vul- 
canite, if  preferred). 

The  plate  was  held  in  position  by  continuous  spring-clasps  of 
iridio-platinum  wire  formed  to  the  buccal  surface  of  the  deciduous 
cuspids  and  molars,  its  ends  extending  in  a  curve  over  the  arch  to  the 
lingual   side   and  attached   in   the   rubber  (Fig.    142).       The   force 

Fig.  142. 


necessary  for  moving  the  lateral  incisors  outward  was  produced  by 
finger-springs,  one  anchored  in  the  vulcanite  on  either  side  of  the 
arch,  extending  forward  and  crossing  to  the  opposite  side,  where 
the  free  end  was  held  in  position  on  the  lingual  side  of  the  lateral 
by  a  lug  on  a  collar  cemented  to  it. 

The  action  of  these  springs  not  only  moved  the  lateral  incisors 
outward,  but  assisted  the  spring  base-wire  in  expanding  the  arch. 
The  loop  in  the  centre  was  opened  as  often  as  necessary,  and  the 
finger-springs  were  at  the  same  time  bent  forward.  These  soon  had 
to  be  lengthened  to  follow  the  movement  of  the  laterals.  This  was 
accomplished  by  using  pieces  of  iridio-platinum  wire,  with  two  narrow 
rings  of  gold  plate  so  attached  with  solder  that  they  would  pass 
over  the  ends  of  the  sprmgs.     They  were  adjusted  by  slipping  them 


166 


INCISORS 


forward  to  attain  the  desired  lengtli.  As  the  laterals  moved  outward 
the  springs  were  necessarily  bent  to  pass  in  front  of  the  loop.  The 
plate  was  inserted  in  September,  and  the  following  February  the  teeth 
were  in  position. 

The  appliance  for  regulating  is  easily  made  and  adjusted,  does  not 
interfere  witli  the  articulation  or  mastication,  and  can  readily  be 
removed  by  the  patient  for  cleansing.  Any  degree  of  force  can  be 
exerted  that  is  desired  ;  the  front  part  of  the  arch  can  be  expanded, 
and  the  distal  part  not  changed,  or  vice  versa. 

For  retaining,  a  wire  device  was  applied  as  seen  in  Fig.  143,  and 
worn  for  several  months.     (For  description  of  making,  see  Chapter 

Fig.  143. 


XXVIII.,  Retaining.)  This  device,  with  attachments,  is  also  utilized 
for  the  regulation  of  the  teeth.  In  the  case  illustrated  the  lateral 
incisors  were  but  partially  erupted,  one  of  them  projecting  only 
a  little  above  the  margin  of  the  gum.  It  was  found  advisable  to 
attach  an  additional  wire  to  the  main  bar  passing  on  the  palatal 
side,  and  bent  to  project  downward  in  the  form  of  a  partial  loop 
back  of  each  of  the  lateral  incisors  for  moving  them  farther  outward, 
retaining  them,  and  at  the  same  lime  stiffening  the  appliance,  the 
wire  being  attached  with  solder  at  the  median  line  and  at  each  end. 

Pieces  of  plate-metal  can  be  attached  to  the  wire  in  this  manner 
for  moving  or  retaining  teeth  by  soldering  to  it  a  spur  of  suitable 
shape  to  project  upward  or  downward  as  recjuired. 

An  appliance  that  is  effective  in  some  cases  where  the  incisors 
need  to  be  moved  outward  is  made  with  springs  extending  from  a 
base-wire  or  a  plate  to  the  labial  side  of  those  teeth.     Finger-springs 


LOWER   INCISORS,  TO   MOVE   OUTWARD  167 

are  attached  to  the  plate,  one  on  either  side,  passing  over  the  arch 
at  the  junction  of  two  of  the  teeth,  cither  in  front  or  back  of  the 
hrst  l)icuspids,  and  curved  forward  to  cross  the  necks  of  the  teeth 
near  the  gum  line,  thus  passing  each  other,  tiie  ends  sometimes 
extending  to  the  opposite  side  of  the  arch.  Collars  are  cemented  to 
the  teeth  to  be  moved,  with  hooks  on  the  labial  side  to  engage  with 
the  ends  of  the  springs,  or  the  springs  can  be  secured  to  the  teeth 
with  ligatures.  The  latter  method  is  not  as  cleanly,  but  is  at  times 
effectual.  The  force  for  the  outward  movement  of  ttie  teeth  is 
caused  by  bending  outward  tlie  finger  portion  of  the  springs. 

The  same  style  of  apparatus  can  be  used  for  contracting  the 
anterior  part  of  the  arch. 

When  there  is  insufficient  anchorage  for  moving  the  lower  incisors 
outward,  as  after  the  loss  of  some  of  the  molar  teeth  or  other  cause, 
exte)-u((l  Hupplementul  force  can  be  employed.  A  chin-cap,  with 
wire  standards  supported  by  a  cranial-cap,  is  carefully  fitted  to  the 
lower  jaw  (Fig.  144).  The  standards  are  adjusted  by  forming  and 
finally  soldering  to  tlie  chin-cap  a  heavy  wire,  about  No.  8  gauge, 
projecting  backward  and  then  curved  upward  to  rest  a  little  in 
front  of  tlie  ear  on  each  side  of  the  head,  and  to  pass  through 
short  perpendicular  tubes  on  the  band  of  the  cranial-cap.  The 
latter  is  made  of  crocheted  silk-twist  attached  to  a  heavy  ribbon- 
band,  as  described  on  page  97  (Anchorage  and  Appliances).  On  the 
side  of  the  ribbon-band,  above  and  in  front  of  the  ear,  is  sewn  a  long 
strip  of  stiff  plate-metal,  a  little  narrower  than  the  band  and  properly 
shaped,  to  which  the  eyelet  for  the  passage  of  the  standard  and  two 
hooks  are  soldered,  one  in  front  and  the  other  back  of  it.  To  these 
hooks  is  attached  a  rubber  band,  which  is  drawn  downward  and  passed 
over  an  adjustable  knob  with  a  screw  on  the  standard.  The  knob  is 
so  located  as  to  cause  just  sufficient  tension  on  the  band  to  sustain  the 
device.  A  labial  spring  is  attached  to  the  chin-cap,  shaped  to  pro- 
ject upward  opposite  the  lips.  It  is  generally  made  by  bending  a 
wire  sharply  on  itself  and  extending  parallel  downward  to  the 
chin,  the  ends  separated,  shaped  to  the  chin-cap,  and  soldered.  The 
spring  can  be  connected  with  the  teeth  in  any  convenient  manner. 
When  the  apparatus  in  the  mouth  used  for  moving  outward  the 
incisors  is  retained  witli  collars,  a  curved  wire  may  extend  from  them 
or  the  apparatus  over  the  lower  lip  to  the  labial  spring,  or  an  inde- 
pendent means  of  attachment  may  be  made.     If  the  curved  wire 


168  INCISOES 

slips  up  or  clown,  prevent  it  by  notching  the  front  of  the  spring,  or 
by  flowing  onto  it  a  little  solder.  Force  is  got  by  bending  outward 
the  end  of  the  spring  from  time  to  time.  It  can  be  utilized  in  mov- 
ing forward  the  cuspids,  bicuspids,  or  molars  on  one  or  both  sides 
of  the  arch ;  or  for  moving  any  of  the  teeth  outward  from  the 
median  line,  as  in  lateral  expansion  of  tiie  arch,  sometimes  attaching 
two  or  more  springs  to  the  chin-cap. 

For  the  correction  of  some  conditions,  an  infralabial  bar,  made  sim- 
ilar to  Figs.  212-214  is  preferable.  It  should  be  attached  to  the  teeth, 
the  arms  curving  over  the  lower  lip,  and  a  rubber  band  passed  over 
each  of  the  knobs  on  the  arms  and  the  adjustable  knobs  on  the 
standards ;  or  a  bar  similar  to  Fig.  373  may  be  applied,  the  metal 
loops  being  opened  a  very  little  at  a  time  to  cause  force.  By  either 
of  these  arrangements  the  bar  is  held  in  a  nearly  constant  relation- 
ship with  the  chin  during  the  movements  of  the  jaw. 

A  device  arranged  in  the  manner  shown  in  Fig.  144  is  suitable 
for  the  treatment  of  both  simple  and  compound  fractures  of  the 
lower  jaw.  In  compound  fractures  the  lateral  body  of  the  jaw  is 
generally  tipped  inward  and  the  lower  end  of  the  ramus  drawn  for- 
ward and  outward.  The  chin-cap  should  first  be  formed  in  the 
shape  that  is  desired  for  the  jaw.  It  should  extend  beyond  the 
fractured  portion  and  be  bent  inward,  or  sufficiently  padded  to  give 
the  required  force,  or  a  spring  should  be  attached  for  causing  pressure 
at  any  point.  Wires  may  be  extended  from  splints  arranged  inside 
of  the  arch  and  pass  over  the  lower  lip,  to  be  fastened  to  the  chin- 
cap  by  passing  into  tubes  (Fig.  380),  or  attached  to  the  cap  in  any 
other  suitable  manner.  The  wires  extending  from  the  splints  to  the 
chin-cap  are  bent  for  drawing  outward  and  supporting  different  por- 
tions of  the  jaw.  When  the  jaw  is  fractured  near  the  angle,  the 
upward  tension  should  be  but  slight. 

Many  variations  from  this  form  of  apparatus  have  been  devised. 
Some  of  the  more  important  are  described. 

Upper  Incisors,  to  move  Outward. — In  moving  upper  incisors 
outward,  they  should  always  be  moved  a  little  farther  than  it  is 
intended  they  shall  remain  when  the  regulating  is  completed.  Es- 
pecially is  this  necessary  when  they  are  not  long  enough  to  lap  well 
over  the  lower  ones.  In  any  case  where  the  teeth  are  short  and  are 
not  naturally  well  retained  in  their  new  position,  a  proper  retaining 
device  should  be  worn,  made  in  such  a  manner  as  to  encourage  the 


Fig.  144. 


UPPER  INCISORS,  TO   MOVE  OUTWARD 


169 


Fig.  145. 


lengthening  of  the  teeth  that  have  been  moved.  Otherwise,  when 
the  jaw  contracts,  as  is  always  the  case  when  new  deposit  of  bone 
takes  place  after  the  movement  of  the  teeth,  they  are  liable  to  draw 
backward  in  the  line  of  the  arch  and  rest  in  occlusion  on  the  in- 
cisive edge  of  the  lower  ones.  In  no  case  should  this  condition  be 
permitted  to  continue. 

When  articulating  in  this  manner,  the  edges  of  the  teeth  are 
usually  worn  away,  and  as  tlie  surface  becomes  worn  the  lower 
incisors  gradually  take  a  position  in  front  of  the  upper  ones,  encour- 
aging the  lower  jaw  to  become  prominent. 

A  simple  device  for  moving  outward  an  instanding  upper  incisor 
is  seen  in  Fig.  1 45.  A  thin  broad  collar,  with  a  tube  soldered  per- 
pendicularly across  the  labial  side 
near  the  centre,  is  cemented  to  the 
tooth  to  be  moved,  the  tube  being 
shorter  than  the  width  of  the  collar 
and  just  large  enough  to  admit  a 
suitably  formed  spring-wire.  The 
spring  is  shaped  by  bending  the 
end  at  a  right  angle  to  enter  the 
tube  and  cross  the  labial  surface  of  an  adjoining  tooth,  where  it  is 
bent  back  on  itself  to  extend  in  a  labial  curve  and  rest  on  the 
adjoining  teeth  on  the  opposite  side.  Force  is  applied  by  bending 
outward  the  shorter  arm  of  the  spring  and  pressing  it  into  the  tube 
on  the  collar,  usually  from  above  downward.  The  spring  is  arranged 
so  that  when  the  tooth  is  moved  outward  sufficiently  the  longer  arm 
of  the  spring  rests  over  the  end  of  the  tube,  preventing  its  accidental 
displacement.     The  utility  of  this  device  is  apparent ;  it  is  applicable 

also  for  moving  other  teeth,  and 
for  retaining. 

Fig.  146  illustrates  a  double  arm 
spring  device  for  moving  outward 
an  incisor.  To  the  tooth  to  be 
moved  is  cemented  a  broad  collar 
with  a  long  tube  attached  hori- 
zontally across  the  front.  Two 
holes  are  drilled  through  the  sides  of  the  tube,  one  near  either  end, 
parallel  with  the  face  of  the  collar.  A  small  spring-wire  is  shaped  to 
cross  the  labial  side  of  the  adjoining  teeth,  curved  back  upon  itself, 


Fig.  146. 


170 


INCISORS 


with  the  ends  bent  at  a  right  angle  to  enter  the  openings  made  in  the 
tube.  The  lower  portion  of  the  spring  should  be  made  to  pass  close 
underneath  the  tube  in  order  to  hold  it  in  place  after  regulation. 
Force  is  applied  by  bending  forward  the  arms  of  the  spring  and 
pressing  them  backward  to  enter  the  holes  in  the  tube.  To  support 
tliis  style  of  spring,  when  it  is  desired,  two  short  tubes  can  be 
soldered  perpendicularly  to  the  labial  surface  of  the  collar,  in  place 
of  the  horizontal  tube,  one  near  the  mesial  and  the  other  near  the 
distal  side.  When  the  tooth  to  be  moved  is  twisted,  for  its  correc- 
tion, more  force  can  be  exerted  on  one  of  the  arms. 

When  a  tooth  is  to  be  moved  but  a  short  distance,  a  spring  can 
sometimes  be  soldered  directly  to  the  collar,  the  ends  being  bent 
backward  sufficiently  to  give  the  necessary  force. 

Fig.  147  shows  a  looped  spring  device  for  increasing  space  and 
moving  outward  an  incisor.     It  was  used  to  advantage  for  correcting 


Fig.  14; 


Fig.  148. 


the  position  of  an  extreme  instanding  upper  central  for  Master  S., 
aged  ten  years. 

To  the  tooth  is  cemented  a  broad  collar  with  a  narrow  strip  of 
plate-metal  soldered  to  the  labial  surface,  forming  a  box-shaped 
opening,  as  already  described  for  moving  outward  a  lower  incisor. 
The  opening  should  be  a  little  broader  at  the  top.  Into  it  is  fitted 
a  small  .spring-wire,  bent  into  the  form  of  a  loop.  Just  below  the 
loop  the  ends  are  curved  upward  and  at  a  right  angle  to  rest  on  the 
labial  laces  of  the  adjoining  teeth.  The  spring  is  held  in  place  by 
separating  a  little  the  sides  of  the  loop.  Force  for  moving  the  tooth 
is  procured  by  bending  backward  the  arms  of  the  spring  before 
adj  usting. 

Sometimes  the  ends  of  the  sjjring  can  be  bent  farther  upward  to 
advantage,  but  they  should  not  rest  higher  than  a  line  with  the  edge 
of  the  gum  on  the  tooth  being  moved. 

In  Fig.  148  is  shown  a  device  with  two  independent  springs  for 


UPPER   I^'CISOKS,  TO    -MOVE  OUTWARD 


171 


moving  outward  an  upper  incisor,  made  as  described  in  moving  out- 
ward a  lower  incisor.  A  broad  collar  is  cemented  to  the  tooth  with 
two  perpendicular  tubes  a  little  shorter  than  tlic  width  of  the  collar 
soldered  to  the  labial  surface,  one  located  near  the  mesial  and  the 
other  near  the  distal  side.  The  springs  are  formed  into  U-shaped 
loops  as  broad  as  the  length  of  the  tube,  with  one  arm  shorter  than 
the  other.  Near  the  curved  portion  of  the  loop  the  short  arm  is 
bent  at  a  right  angle  to  enter  the  tube,  usually  from  above  down- 
ward. The  end  of  the  loop  rests  on  the  collar  near  the  median  line, 
with  the  long  arm  extending  across  the  adjoining  tooth.  Force  with 
the  springs  is  produced  by  bending  forward  the  short  arms  a  little  at 
a  time  and  springing  them  back  into  tlie  tubes. 

A  device  for  moving  outward  two  incisors  is  shown  in  Fig.  149. 
A  collar  with  a  tube  soldered  horizontally  or  perpendicularly  to  the 


Fig.  149. 


Fig.  150. 


labial  side  is  cemented  to  each.  A  medium-sized  spring  is  shaped 
to  the  desired  labial  curve  of  the  arch,  extending  across  two  of  the 
teeth  either  side  of  those  to  be  moved,  and  curved  back  on  itself,  run- 
ning parallel  with  the  ends  bent  at  a  right  angle  to  enter  holes  in  the 
tubes.  The  long  portion  of  the  spring  can  be  stiffened  if  required  by 
soldering  to  it,  underneath,  a  wire  or  a  narrow  strip  of  thin  plate-metal. 

For  moving  two  lateral  incisors,  when  there  is  sufficient  space  and 
the  centrals  are  in  good  position,  a  device  as  shown  in  Fig.  150  is 
sometimes  efficient.  A  thin  broad  collar  with  an  eyelet  or  short  tube 
attached  on  the  labial  surface  is  cemented  to  each.  A  small  spring 
is  shaped  to  cross  the  labial  side  of  the  centrals.  Near  the  distal 
surface  of  each  the  spring  is  curved  upward  a  little  into  a  loop  with 
the  free  ends  projecting  downward  to  enter  the  eyelets  or  tubes 
described. 

Force  is  applied  by  bending  the  ends  of  the  loops  forward  and 
pressing  them  back  into  the  eyelets. 


172 


INCISORS 


For  moving  upper  central  and  lateral  incisors  outward,  an  ap- 
pliance is  made  by  arranging  spring-clasp  attachments  for  anchorage 
over  a  molar  or  bicuspid  on  each  side,  with  partial-clasps  on  the  ad- 
joining teeth,  and  forming  a  palatine  base-wire,  about  No.  13  gauge, 
to  cross  the  arch,  with   the  ends  bent   nearly  at  a   right  angfle  to 


cross  the  partial-clasps  (Fi^ 
Fig.  161. 


151). 


right  angle 
Usually  a  collar  witli  a  large  lug 
on  the  palatal  side  should 
be  cemented  to  each  of  the 
teeth  to  be  moved  outward. 
A  spring-wire,  about  No. 
18  gauge,  is  formed  in  a 
gentle  curve  to  rest  on  the 
lingual  side  of  the  incisors 
passing  underneath  the  lugs. 
A  loop  about  one-half  inch 
long  is  formed  in  the  wire 
on  each  side  opposite  the 
first  bicuspids,  pointing  to- 
wards the  median  line,  and  contoured  to  rest  near  the  soft  tissues, 
its  ends  extending  across  the  partial-clasps,  to  which  they  are 
soldered  in  the  anchorage  portion.  Force  for  moving  the  incisors  is 
obtained  by  opening  the  loops  in  the  spring-wire  a  little  with  round- 
nosed  pliers  or  other  instru-  p^  -^-2 
ment  once  in  four  or  five  days. 
The  base-wire  can  be  made 
to  follow  the  lingual  curve  of 
the  arch,  using  a  finger-spring, 
but  it  is  more  liable  to  in- 
terfere with  pronunciation. 

Moving  outward  an  incisor 
in  some  difficult  conditions  of 
the  occlusion  of  the  teeth  is 
accomplished  by  the  device 
showrt  in  Fig.  152.  A  spring 
base-wire  is  formed  loosely  to  the  labio-buccal  side  of  the  teeth,  and 
following  the  gum  line  back  on  either  side  to  a  bicuspid  or  molar,  to 
which  it  is  anchored. 


*  Jackson,  Transactions  Columbian  Dental  Congress,  V(j1.  ii.  p.  675. 


UPPER  INCISORS,  TO  MOVE  OUTWARD 


173 


It  will  be  observed  that  if  the  teeth  are  crowded  the  arrangement 
of  the  base-wire  passing  on  the  labial  side  of  the  teeth  would  not 
permit  them  to  separate  sufficiently  to  allow  the  incisors  to  be  moved 
into  place.  This  difficulty  is  obviated  by  making  a  loop  in  the  base- 
wire  near  one  of  the  spring-clasp  attachments,  which  can  be  opened 
sufficiently  from  time  to  time  to  enlarge  the  circle  of  the  arch  as 
desired.  A  small  wire,  about  No.  20  gauge,  is  bent  into  the  form 
of  a  spring-clasp  for  moving  the  incisor,  crossing  the  lingual  surface, 
the  ends  extending  either  side  over  the  arcli  at  the  junction  of  the 
teeth,  near  tlie  incisive  edge,  and  soldered  to  the  base-wire.  The 
arms  of  the  spring  can  be  bent  outward  for  broadening  the  space 
for  the  movement  of  the  tooth,  and  the  part  that  crosses  the  lingual 
side  bent  nearer  the  base-wire  from  time  to  time  for  forcing  the 
tooth  into  position. 

In  some  instances  it  is  an  advantage  to  have  the  spring  reversed, 
with  the  free  ends  resting  on  the  lingual  side  of  the  incisor  and  the 
part  between  the  parallel  arms  united  to  the  base-wire.  In  this 
case  the  parallel  arms  of  the  spring  can  be  utilized  for  increasing  the 
space  as  before,  and  the  ends  bent  towards  the  base-wire  for  causing 
the  outward  movement  of  the  tooth.  If  the  spring  is  not  well  re- 
tained on  the  incisor,  a  thin 
collar  with  a  small  lug  on  the 
palatal  side  can  be  cemented 
toil. 

In  Fig.  153  it  will  be  seen 
that  the  right  upper  incisor  is 
too  prominent,  and  the  left  in- 
cisor not  prominent  enough 
and  partially  rotated. 

The  irregularity  was  cor- 
rected by  a  spring-clasp  at- 
tachment made  to  the  second 

right  deciduous  molar  for  anchorage,  and  extending  forward  from  this 
a  spring-wire  following  the  labial  surface  of  the  teeth  near  the  gum 
line,  crossing  the  right  incisor,  and  extending  into  a  tube  soldered  to  a 
collar  cemented  to  the  left  incisor.  A  hook  attached  to  the  collar  can 
be  used  in  place  of  the  tube  if  desired.  By  removing  the  appliance 
and  straightening  the  end  of  the  spring  slightly,  pressure  was  ex- 
erted on  the  right  incisor,  forcing  it  inward,  while  at  tlie  same  time, 


174 


INCISORS 


acting  as  a  lever,  it  drew  forward  sufficiently  to  move  the  left  incisor 
outward  to  line  and  to  rotate  it.  A  similar  appliance  has  been  used 
with  marked  success  for  rotating  teeth.  (See  Chapter  XIV.,  Incisors, 
to  rotate.) 

Fig.  154  shows  the  shape  of  a  spring  that  was  used  for  moving 
outward  both  of  the  upper  lateral  incisors,  which  had  erupted  con- 

FiG.  154. 


siderably  inside  of  the  circle  of  the  arch,  closing  back  of  the  lower 
teeth. 

The  spring  was  made  to  extend  across  the  labial  side  of  the  in- 
cisors to  the  distal  side  of  the  laterals  at  the  gum  line.  The  ends 
were  formed  into  loops  to  pass  over  the  arch  at  the  junction  with 
the  adjoining  teeth  to  the  lingual  side,  and  bent  again  at  a  right  angle 
to  cross  the  lingual  side  of  the  laterals.  If  the  central  incisors  are 
rotated,  and  their  position  needs  correcting,  the  spring  should  extend 
on  to  the  linguo-distal  side  of  them.  It  is  usually  to  be  retained  by 
cementing  a  collar  with  a  lug  on  the  lingual  side  on  each  of  the 
lateral  incisors.  It  will  be  seen  that  by  removing  the  spring,  straighten- 
ing the  main  portion  slightly,  and  replacing  it,  it  will  exert  a  pressure 
outward  on  the  lateral  incisors  and  a  corresponding  drawing  inward 
on  the  mesial  .side  of  the  centrals. 

This  stylo  of  appliance  can  be  used  for  rotating  the  central  inci- 
sors alone  in  the  same  manner. 

In  this  case  the  cuspids  had  erupted  in  front  of  the  lateral  inci- 
sors. Their  position  being  such  as  not  to  warrant  their  being  moved 
to  the  position  of  the  first  bicuspids,  they  were  extracted. 

When  one  or  two  incisors  are  erupted  posterior  to  the  natural 
position  in  the  line  of  the  arch,  with,  as  is  often  the  case,  the  first 


UPPER  INCISORS,  TO   MOVE  OUTWARD 


175 


deciduous  molars  decayed  or  missing,  causing  a  space,  an  appliance 
like  Fig.  155  will  sometimes  be  sufficient  to  correct  the  irregularity. 
It  is  made  of  spring-wire  about  No.  1 7  gauge.  A  loop  is  first  formed 
to  pass  through  the  space,  with  one  end  following  the  lingual  and 
the  other  the  labial  curve  of  the  arch,  extending  to  or  a  little  beyond 

Fig.  155. 


the  teeth  to  be  moved.  The  spring  on  the  labial  side  is  usually  a 
little  longer  than  the  one  on  the  lingual.  The  appliance  is  retained 
by  placing  a  collar  with  a  lug  in  suitable  position  on  one  or  more 
teeth. 

If  the  power  of  the  spring  is  found  to  be  insufficient,  a  wire  of  a 
larger  size  can  be  substituted,  or  a  silk  ligature  may  be  passed  be- 
tween the  teeth,  looped  around  each  wire  near  its  end  and  tied  to 
draw  the  springs  together  for  causing  additional  pressure.  If  the 
permanent  teeth  are  erupted,  and  there  is  no  space  for  tlie  looped 
part  of  the  wire  to  pass  from  the  labial  to  the  lingual  side,  the  ap- 
pliance described  can  be  made  efficient  by  bending  the  end  of  the 
loop  at  a  right  angle  with  the  springs,  and  shaping  it  to  lie  over  the 
arch  at  the  junction  of  two  of  the  teeth.  This  is  accomplished 
by  placing  the  end  of  the  loop  in  fiat-nosed  pliers  or  a  vise,  and 
bending  at  once  to  the  reciuired  angle  ;  being  careful  to  have  the 
loop  so  shaped  as  not  to  interfere  with  the  closing  of  the  teeth,  and 
retaining  the  spring  with  collars  and  lugs  on  the  teeth  as  previously 
described. 

This  method  is  only  thoroughly  applicable  in  a  few  cases,  and  for 
this  reason  I  refer  the  reader  to  some  of  the  following  methods. 
The  principle  is  utilized  in  the  case  next  described. 


176 


INCISORS 


Fig.  1 56  shows  a  device  used  for  the  correction  of  crowded  inci- 
sors ;  some  of  them  being  too  prominent,  others  needing  to  be 
moved  outward  and  rotated.  It  is  made  by  first  bending  a  spring- 
wire  into  the  form  of  a  loop  to  pass  on  the  labial  and  lingual  faces 


Fig.  156. 


of  the  irregular  incisors  at  the  gum 


line,  the  end  of  the  loop  being  bent 
upward  to  pass  over  the  arch  at 
the  junction  of  the  lateral  with 
the  cuspid.  A  lingual  spring  base- 
wire  is  sliaped  to  the  inner  curve 
of  the  arch,  provided  with  a  U- 
shaped  loop  or  with  corrugations 
opposite  the  bicuspids  on  either 
side,  and  the  ends  anchored  witli 
spring-clasp  attachments  over  the  first  molars.  The  lingual  arm  of 
the  looped  spring  is  attached  to  the  base-wire  by  winding  about 
them  a  narrow  strip  of  metal  at  the  median  line  and  uniting  them 
with  solder.  A  collar  with  a  lug  on  the  lingual  side  should  be 
cemented  to  one  or  more  of  the  incisors  to  assist  in  retaining  the 
appliance.  The  loops  in  the  base-wire  are  opened  from  time  to 
time  with  round-nosed  pliers,  to  give  pressure  for  moving  the 
irregular  teeth  outward  until  there  is  sufficient  space  in  the  circle 
for  all  of  them,  in  corrected  positions.  As  the  incisors  are  being 
moved,  the  anterior  arm  of  the  looped  spring  is  bent  to  assume  a 
position  nearer  to  the  base-wire,  thus  exerting  pressure  on  the  labial 
and  lingual  sides  of  the  teeth,  moving  them  laterally  into  the  curve 
prescribed  by  the  form  of  ^^^  2^^ 

the  spring.     The  appliance  :.:-/:::.-:.,-::-:^.,,,,:^'^r-,,... 

is  made  more  substantial 
by  the  addition  of  a  palatine 
base-wire. 

The  practicability  of  using 
a  simple  spring-wire  to  cor- 
rect an  irregularity  indepen- 
dent of  spring-clasp  attach- 
ments, collars,  etc.,  for  anchorage,  was  demonstrated  many  years  since.* 
Fig.  1 57  shows  the  tooth  of  a  girl  eight  years  of  age,  with  the  upper 


*  Jackson,  International  Dental  Journal,  1890,  p.  202. 


UPPER  INCISORS,  TO   MOVE  OUT\YARD 


177 


Fig.  158. 


central  incisors  erupted  inside  of  tlie  circle  of  the  lower  ones.  For 
their  correction,  a  collar  witii  a  good-sized  lug  on  the  lingual  side  was 
cemented  to  each  of  the  central  incisors. 

A  semicircular  spring-wire  was  shaped  to  the  lingual  contour  of  the 
arch,  with  a  loop  on  either  side  terminating  in  the  form  of  the  letter 
S,  and  the  end  made  to  project  into  a  hole  drilled  in  a  filling  that  had 
been  inserted  in  each  of 
the  second  deciduous  mo- 
lars (Fig.  158).  The  force 
was  controlled  by  slightly- 
opening  the  loops  in  the 
ends  of  the  spring.  It  re- 
quired but  six  changes  to 
complete  the  regulating. 

A  spring-clasp  attach- 
ment for  anchorage  is  so 
easily  made  and  retained 
on  the  second  deciduous 

molars  that  its  use  is  recommended  in  all  cases,  even  though  the 
teeth  be  badly  decayed  and  are  becoming  loose. 

The  importance  of  the  early  treatment  of  instanding  upper  inci- 
sors is  clearly  shown  in  this  case.  If  they  are  not  moved  outw^ard 
early,  they  induce  an  unnatural  prominence  or  prognathous  con- 
dition of  the  lower  jaw. 

Fig.  159  is  interesting  as  illustrating  the  imprudence  of  a  too  early 
extraction   of  the   deciduous   teeth.     The  patient  was  a  boy  nine 

years  of  age.  When  he  came 
under  treatment  both  of  the 
second  deciduous  molars  in 
the  upper  arch  had  long  been 
removed,  and  the  first  per- 
manent or  sixth-year  molars 
had  moved  forward,  occupy- 
ing much  of  the  space  that 
should  have  been  reserved  for 
the  second  bicuspids.  Thus, 
owing  to  the  lack  of  lateral 
support  in  the  arch,  caused  by  the  loss  of  the  deciduous  molars,  when 
the  permanent  incisors  erupted   they  took  a  position  back  of  the 

12 


Fig.  159. 


178  INCISORS 

lower  ones.  They  were  broader  than  the  deciduous  incisors,  and 
caused  the  adjoining  teeth  to  move  backward  in  the  circle  of  the  arch, 
which,  with  the  forward  movement  of  the  molars,  nearly  closed  the 
space  between  them  and  the  first  bicuspids  which  were  erupted. 
These  abnormal  changes,  entirely  due  to  the  early  loss  of  the  deciduous 
molars,  made  it  quite  impossible  for  the  second  bicuspids  to  erupt  in 
their  natural  position  in  the  circle  of  the  arch,  or  for  the  upper  incisors 
to  gain  their  proper  place  in  front  of  the  lower  ones  without  mechan- 
ical interference. 

To  move  the  incisors  outward  to  a  normal  position,  and  to  remedy 
the  impacted  state  of  the  second  bicuspids,  an  appliance  was  made 
by  forming  a  spring-clasp  attachment  for  anchorage  over  each  of  the 
first  permanent  molars,  connected  with  a  palatine  base-wire.  A 
collar  with  a  lug  on  the  lingual  side  was  cemented  to  one  of  the 
central  and  one  of  the  lateral  incisors,  for  the  purpose  of  retaining 
a  semicircular  spring-wire.  The  spring  was  bent  to  follow  the  lingual 
curve  of  the  teeth,  passing  underneath  the  lugs,  and  formed  into  a 
U-shaped  loop  either  side,  about  three-eighths  of  an  inch  long,  point- 
ing towards  the  median  line,  and  resting  near  the  gum  opposite  the 
first  bicuspids,  the  ends  of  the  spring  crossing  the  partial-clasps, 
to  which  they  were  soldered  with  the  base-wire.  By  slightly  opening 
the  loops  in  the  spring  once  hi  three  or  four  days,  pressure  was 
brought  to  bear  that  moved  the  incisors  outward  ;  while  also  the 
molars  used  for  anchorage  gradually  yielded  and  moved  backward, 
thus  making  room  for  the  eruption  of  the  second  bicuspids. 

This  case  illustrates  the  necessity  of  preserving  the  deciduous 
molars  until  about  the  time  of  the  eruption  of  the  bicuspids.  When 
deciduous  molars  have  been  removed  the  case  should  be  examined 
from  time  to  time,  and  if  the  spaces  for  the  bicuspids  are  being 
closed  by  the  backward  movement  of  the  teeth  in  front  of  them, 
and  by  the  forward  movement  of  the  first  permanent  molars,  an 
apparatus  should  be  inserted  to  move  them  to  a  correct  position  and 
to  retain  them  until  the  eruption  of  the  bicuspids. 

Fig.  160  shows  tlie  appliance  used  for  moving  outward  an  upper 
central  and  lateral  incisor  that  were  closing  back  of  the  lower  ones, 
with  the  cuspid  erupting  somewhat  in  front  of  the  lateral  The 
patient  was  a  boy  aged  eleven  years.  A  spring-clasp  attachment  for 
anchoring  the  appliance  was  formed  to  clasp  the  left  upper  molar  on 
one  side  and  the  bicuspid  on  the  other;    it  was  connected  with  a 


UPPER  INCISORS,  TO   MOVE   OUTWARD 


179 


palatine  base-wire,  having  one  end  bent  backward  and  the  other 
forward  to  cross  the  partial-clasps.  A  spring-wire  was  then  formed 
to  the  lingual  curve  of  the  yig.  160. 

incisors,  crossing  the  ones  to 
be  moved,  and  a  U-shaped 
loop  made  in  either  side, 
pointing  towards  the  median 
line,  its  ends  extending  back- 
ward to  cross  the  partial- 
clasps,  to  be  united  with 
solder  to  them  and  to  the 
base-wire.  To  retain  the 
spring  a  collar  with  a  lug  on 
the  lingual  side  was  cemented 
to  the  central  incisor  to  be  moved.  A  collar  should  also  be  cemented 
to  the  lateral.     The  regulating  was  completed  in  eleven  visits. 

In  some  cases  the  spring  made  with  a  loop  on  each  side  of  the 
arch  acts  more  certainly  than  with  the  finger-spring,  and  the 
force  is  easily  controlled  by  bending  with  round-nosed  pliers ;  but 
the  loop  should  be  long  to  insure  springiness. 

Usually  upper  incisors  that  have  a  lingual  occlusion  and  have  been 
moved  labially,  when  fully  erupted  are  retained  by  their  natural  ar- 
pjg  j^gj  ticulation.     In   this   case,  the 

incisors  being  shorter  than 
usual,  they  did  not  close  well 
over  the  lower  teeth.  The 
erupting  cuspid  was  promi- 
nent, and  therefore  tended 
to  wedge  the  lateral  incisor 
inward  towards  its  original 
position.  To  retain  the  lateral 
a  platina-gold  collar  was  fitted 
to  it  with  a  spur  of  thin,  flat 
metal  soldered  to  the  lingual 
side,  projecting  a  little  below 
the  incisive  edge  of  the  tooth  in  order  to  lengthen  it  and  make  it 
close  in  front  of  the  lower  incisors  (Fig.  505). 

In  Fig.  161  a  convenient  appliance  is  shown  for  moving  outward 
the  upper  incisors.     A  spring-clasp  attachment  is  formed  over  one  of 


180 


INCISORS 


the  molars  or  bicuspids  on  eitlier  side  of  the  arch,  with  partial-clasps 
on  the  adjoining  teeth  for  anchorage,  and  connected  with  a  palatine 
base-wire.  To  the  partial-clasps  on  each  side  is  soldered  a  long 
semicircular  fmger-spring,  shaped  to  project  forward  following  the 
Ungual  curve  crossing  the  teeth  to  be  moved ;  it  terminated  on 
the  opposite  side  of  the  arch,  the  springs  resting  parallel  one  with 
the  other.  A  collar  with  a  rather  broad  lug  on  the  lingual  side  is 
cemented  to  two  or  more  of  the  teeth  to  be  moved  to  retain  the 
ends  of  the  springs.  Force  is  applied  by  bending  the  springs  outward 
a  little  as  required. 

Sometimes  in  cases  where  there  is  a  close  articulation,  the  lower 
incisors  biting  against  the  gum  back  of  the  upper  ones,  it  is  difficult 
to  arrange  a  device  inside  of  the  arch  for  moving  outward  an  upper 
incisor  without  interfering  with  the  occlusion.  In  such  a  case  an 
appliance  made  as  shown  in  Fig.  162  can  be  utilized.     A  palatine 

Fig.  162. 


base-wire,  about  No.  13  gauge,  is  anchored  with  a  spring-clasp  at- 
tachment to  a  molar  or  bicuspid  on  either  side.  To  the  base-wire  or 
partial-clasp  is  attached  a  spring- wire,  No.  1 8  gauge,  shaped  to  pass 
over  at  the  junction  of  two  of  the  teeth  to  the  buccal  side,  and  bent 
forward  following  the  labial  curve  of  the  teeth  crossing  the  incisor  to 
be  moved.  To  llic  incisor  is  cemented  a  coll;!!"  with  a  hook  to 
engage  with  tli(.'  sju-iiig.  Force  for  moving  the  iiTcgular  tootli  is 
caused  by  bending  outward  tlie  end  of  the  spring  from  time  to  time. 
If  required,  two  springs  can  ]je  made  to  extend  forward  in  the 
same  manner,  one  from  either  side. 


UPPER   INCISORS,  TO   MOVE  OUTWARD 


181 


Fi|?.  1G3  exemplifies  a  iiiothod  used  to  force  into  line  a  right  upper 
lateral  incisor  that  was  far  inside  of  the  circle  of  the  arch,  and  at 


i 


K^M^'r^^'^f.--: 


the  same  time  to  move  backward  a  prominent  cuspid  that  rested 
nearly  in  front  of  it,  there  being  sufficient  space  for  its  correction. 
Partial-clasps  and  spring-clasp  attachments  were  formed  to  the  de- 
ciduous molars  for  anchorage  and  connected  with  a  lingual  base- wire. 
A  finger-spring  for  moving  the  lateral  outward  was  then  fastened 
in  the  anchorage  portion  on  the  left  side  and  extended  forward, 
passing  underneath  a  lug  on  the  lingual  side  of  a  collar  cemented 
to  the  lateral.  The  cuspid  was  moved  into  position  by  a  finger-spring 
attached  in  the  anchorage  portion  on  the  right  side.  It  extended 
over  the  arch  just  in  front  of  the  first  deciduous  molar  and  was  bent 

Vh;.  1()4. 


forward  to  clasp  the  labio-niesial  surface  of  the  cuspid.  Force  was 
applied  by  bending  the  springs  slightly  at  a  time.  An  appliance  with 
a  palatine  base-wire  and  springs  arranged  in  this  manner  is  equally 
applicable. 

A  boy,  thirteen  years  of  age,  was  brouglit  for  treatment  of  the 
irregularity  shown  in  Fig.  164.     The  left  central  and  both  lateral 


182 


INCISORS 


incisors  closed  back  of  those  of  the  lower  arch.    The  patient  was 
fitted  with  the  appliance  illustrated  in  Fig.  165.     A  lingual  base-wire 

Fig.  165. 


was  shaped  to  follow  the  irregular  line  of  the  arch,  with  the  ends 
anchored  with  spring-clasp  attachments  to  the  second  deciduous 
molars  and  partial-clasps  on  the  adjoining  teeth.  From  the  right 
anchorage  a  finger-spring  was  formed  to  extend  forward,  following 
the  contour  of  the  teeth,  terminating  on  the  distal  side  of  tlie  left 
lateral,  the  action  of  which  was  utilized  for  moving  the  incisors  out- 
ward. Another  spring,  soldered  to  the  base-wire  on  the  left  side, 
passed  just  in  front  of  the  first  bicuspid  and  extended  upward  and 
forward,  with  the  end  resting  on  the  mesio-labial  surface  of  the 
cuspid  near  the  gum  line.  The  effect  of  this  spring  was  to  draw 
the  cuspid  backward  towards  the  bicuspid  and  to  assist  in  making 

Fig.  1H6. 


room  for  the  incisors  in  a  normal  line.     No  collars  were  necessary 
on  the  laterals  or  cuspid  for  retaining  the  appliance. 

It  will  be  observed  that  as  the  left  central  and  lateral  were  moved 
outward  they  were  not  rotated  sufficiently  to  take  a  normal  position. 


UPPER   INCISORS,  TO   MOVE  OUTWARD 


183 


^^ 


An  appliance,  as  shown  in  Fig.  299,  was  used  to  rotate  the  lateral. 
It  was  retained  by  placing  a  gold  collar  around  it  with  a  spur 
extending  to  the  labial  side  of  the  cuspid,  as  seen  in  Fig.  166,  after 
which  the  central  incisor  was  rotated  and  retained  in  a  similar  manner. 

Fig.  167  illustrates  the  case  Fjo.  ig7. 

of  Master  T.,  aged  twelve 
years.  The  lower  central  in- 
cisors rested  in  front  of  the 
upper  ones.  The  upper  cen- 
tra! incisors  and  the  right 
lateral  incisor  closed  in  front 
of  the  lower  lateral  incisors, 
and  the  left  lateral  closed  back 

of  the  lower  lateral  and  cuspid.  The  second  deciduous  molars  of 
the  upper  arch  were  still  in  position  and  were  utilized  for  anchorage, 
although  they  were  badly  decayed  and  somewdiat  loosened  from 
absorption.  The  cavities  were  filled  with  gutta-percha,  and  an  appli- 
ance for  correcting  the  irregularity  of  the  upper  arch  was  made  as  fol- 
lows :  A  collar  with  a  broad  lug  on  the  lingual  side  was  cemented  to 
the  left  lateral  incisor.     A  spring-clasp  attachment  for  anchorage  was 

formed  to  each  of  the  sec- 
ond deciduous  molars  and 
connected  with  a  palatine 
base-wire.     A  small  semi- 
circular sirring  was  shaped 
to  pass  under  the  lug  and  a 
U-shaped  loop  made  in  the 
wire  on  either  side  just  in 
front  of  the  anchorage  por- 
tion, pointing  towards  the 
centre  of  the  arch,  with  the 
-, "  -        ends  soldered  to  the  partial- 
clasps  (Fig.  168). 
This  is  another  illustration  of  the  advantage  of  the  spring-clasp 
attachment  for  anchorage.     A  deciduous  molar  that  is  beginning  to 
become  loose  or  badly  decayed  will  often  be  a  sufficient  anchorage 
for  completing  the  operation. 

After  the  regulation  of  the  upper  incisors  was  begun  an  appliance, 
as  seen  in  Fig.  134,  was  inserted  to  correct  the  position  of  the  lower 


184 


INCISORS 


incisors,  the  spring   being  retained  with  a  collar  on  each   of  the 
laterals.     Both  appliances  Avere  worn  at  the  same  time.     The  action 


Fig.  1G9. 


was  controlled  by  opening  the  loops  of  the  springs.  Fig.  169  illus- 
trates the  completed  case.  The  same  appliances  were  used  for 
retaining. 

Fig.  170  shows  the  occlusion  and  position  of  the  teeth  of  Master 
B.,  aged  fourteen  years.     The  left  upper  lateral  incisor  closed  back 

Fig.  170. 


of  the  lower  cuspid.  The  latter  was  considerably  too  prominent. 
The  second  left  upper  deciduous  molar  had  injudiciously  been 
removed  early,  and  the  permanent  molar  had  tipped  forward,  causing 
impaction  of  the  second  bicuspid.  There  was  insufficient  space  for 
the  right  upper  cuspid,  and  it  had  assumed  a  position  outside  of  the 
circle  of  the  arch.  The  second  right  deciduous  molar  was  still  in 
position. 

Fig.  171  illustrates  a  palatine  view  of  the  upper  arch.  It  was 
determined  to  extract  the  second  deciduous  molar,  it  being  a  little 
broader  than  the  erupting  second  bicuspid,  and  to  move  the  first 


UPPER  INCISORS,  TO  MOVE  OUTWARD 


185 


bicuspid  backward  to  provide  space  for  the  prominent  cuspid.     An 
appliance  was  constructed  as  seen  in  Fig.  172.     A  lingual  base-wire, 


Fig.  171. 


No.  14  gauge,  w^as  formed  to  the  inner  curve  of  the  arch  near  the 
necks  of  the  teeth  and  anchored  with  spring-clasp  attachments  to  the 


Fig.  172. 


first  permanent  molars  and  the  first  left  bicuspid.  A  curved  spring 
was  attached  to  the  base-wire  to  pass  in  front  of  tlie  right  bicuspid 
for  moving  it  backward.  For  further  increasing  the  space  and  draw- 
ing the  cuspid  into  line  a  double  curved  spring,  No.  19  gauge,  was 
soldered  to  the  base-wire  back  of  the  central  incisors.  It  passed 
through  the  space  just  back  of  the  lateral  and  curved  forward  in 
front  of  the  cuspid,  its  end  bent  backward  to  terminate  on  the  labial 


186 


INCISORS 


surface.  The  instanding  lateral  incisor  was  moved  outward  by  a 
long  curved  finger-spring,  No.  19  gauge.  It  was  attached  to  the 
base-wire  on  the  right  side  and  followed  the  lingual  curve  to  the  left 
side,  where  it  crossed  the  lateral  and  was  retained  with  a  lug  on  a 

Fig.  173. 


collar  cemented  to  it.  Another  curved  finger-spring  was  attached 
to  the  partial-clasp  and  base-wire  on  the  left  side,  passing  in  front 
of  the  bicuspid,  with  the  end  shaped  to  rest  on  the  labio-mesial  sur- 
face of  the  cuspid  to  move  it  backward. 

The  appliance  was  inserted  on  April  5  and  force  applied  with 
the  springs.  On  July  25  the  teeth  had  assumed  the  position  seen 
in  Fig.  173,  the  springs  having  been  readjusted  at  intervals. 

Fig.  174. 


Fig.    174   illiislralos  tliu  crowded  condition    of  tiie  teeth   of  the 
lower  arch.     The  left  lateral  incisor  stood  considerably  back  of  the 


UPPER   INCISORS,   TO   MOVE   OUTWARD 


187 


lino  of  the  left  coiitral  incisor  and  cuspid.  The  latter  was  too  promi- 
nent. For  their  correction,  it  was  found  advisable  to  extract  the  first 
left  lower  bicuspid  and  apply  an  apparatus  as  shown  in  Fig.  175. 
A  lingual  base-wire  was  formed  to  the  inner  curve  of  the  arch  and 


anchored  to  the  second  bicuspid  and  first  molar  on  the  left  side, 
and  to  the  bicuspids  on  the  right.  To  provide  space  for  the  irregular 
lateral,  the  cuspid  was  first  drawn  backward  by  a  curved  finger- 
spring  into  the  space  caused  by  the  removal  of  the  bicuspid.  It  was 
attached  to  the  base-wire  next  to  the  second  bicuspid,  and  extended 
outward  and  forward  to  rest  on  the  labio-mesial  surface  of  the 
cuspid.  The  lateral  incisor  was  moved  outward  by  a  finger-spring 
attached  to  the  base-wire  on  the  right  side.  It  projected  forward, 
following  the  lingual  curve.  The  free  end  was  retained  by  a  lug 
on  a  collar  cemented  to  the  lateral. 

Fig.  176. 


This  appliance  was  inserted  June   9,  and  the  following  July  25 
the  teeth  had  taken  the  position  seen  in  Fig.  176. 


II 


INCISORS 


Fig.  1 


The  patient  lived  at  some  distance  from  the  city,  and  owing  to  the 
inconvenience  of  travel  only  twelve  visits  were  made  up  to  this  time. 
The  mother  was  provided  with  a  clasp-bender  and  instructed  to 
make  the  necessary  changes  between  visits.  The  second  left  upper 
bicuspid  finally  made  its  appearance,  pointing  into  the  palatine  arch, 
there  still  being  insufficient  space  for  it  to  take  a  correct  position. 
An  appliance  as  seen  in  Fig.  177  was  inserted  for  increasing  the 

space  and  moving  the  bi- 
cuspid into  line.  A  pala- 
tine base-wire  was  used, 
anchored  with  spring-clasp 
attachments  on  the  first 
molar  on  the  left  side  and 
the  second  bicuspid  on  the 
right.  A  spring-wire  was 
made  to  follow  the  curve 
of  the  arch  near  the  necks 
of  the  teeth ;  opposite  the 
bicuspid  to  be  moved  it  was 
bent  into  a  U-shaped  loop 
pointing  towards  the  median  line  of  the  arch,  its  ends  soldered  in 
the  anchorage  portion  with  the  ends  of  the  base- wire.  To  the 
spring  in  front  of  the  U-shaped  loop  on  the  left  side  was  attached  a 
secondary  spring,  which  projected  backward  and  outward  to  clasp 
the  distal  side  of  the  first  bicuspid,  and  a  finger-spring  extending 
forward  from  the  partial-clasp  to  the  lingual  side  of  the  bicuspid  to 
be  moved.  The  space  was  broadened  by  removing  the  appliance 
from  time  to  time,  and  opening  the  loop  by  bending;  bending  out- 
ward also  the  finger-spring,  which  applied  force  to  the  bicuspid  for 
moving  it  in  a  buccal  direction.  Two  additional  visits  were  required 
for  the  movement  of  the  bicuspid  and  to  complete  the  regulating. 

This  case  is  interesting,  as  its  correction  included  so  many  different 
movements. 

Mrs.  E.  was  referred  to  me  in  November,  1893,  for  advice  re- 
garding her  teeth.*  The  following  history  was  noted  :  Age,  thirty- 
eight  years.  Lower  jaw  prognathous,  the  lower  incisors  closing 
in   front  of  the  upper  ones,  the  other  teeth  articulating  in  nearly 


*  Jackson,  Dental  Cosmos,  1894,  j).  900. 


UPPER  INCISORS,   TO  MOVE  OUTWARD  189 

a  normal  position.     Five   teeth    had    been    extracted,  ah    of  them 
molars. 

In  the  upper  arch  there  remained  four  molars,  two  on  each  side, 
and  three  in  the  lower  arch,  two  on  one  side,  and  one  on  the  other. 
The  crowns  of  the  first  and  second  left  upper  bicuspids  had  been 
removed,  and  porcelain  ones  substituted.  The  crown  of  the  first 
right  upper  bicuspid  had  also  been  removed,  and  an  all-gold  crown 
Avas  in  its  place.  The  gum  about  the  lower  incisors  had  receded, 
and  was  diseased.  The  right  lower  central  incisor  was  somewhat 
loose,  and  was  moved  outward  by  the  upper  incisors  in  occlusion. 
The  labial  faces  of  the  upper  incisors  were  considerably  worn  by  the 
low^er  incisors,  and  appeared  stubby.  The  upper  lip  was  sunken, 
and  the  facial  line  was  not  good.  Year  by  year  the  patient  observed 
that  the  lower  incisors  were  closing  higher  in  front  of  the  upper 
ones.  An  unsuccessful  attempt  to  correct  the  irregularity  had  been 
made  when  the  patient  was  about  twenty-eight  years  of  age. 

AVith  the  assistance  of  the  models  (Fig.  178),  it  was  determined 
that  without  interference  the  lower  incisors  would  gradually  be 
forced  to  take  a  more  prominent  ^^^^  ^„g 

position,  and  one    or   more    of 
them  would  soon  be  so  loose  as  m^m^- 

to    necessitate     their     removal.         ^^ft&  ;  ^      :;4&*^^^^ - 
The     lower     jaw,     meanwhile.        ^^^     ¥^^n         r      ^^fe 
would  become  more  prominent,    rf^M!!^    A     Ol    i tf ^ .|_ jii*'*''*NiiWl||'i 
the  upper  lip  more  sunken,  and    |  I     f^  fT '  "^    i     ^^^^^^5^' 
the  upper  incisors  more  worn.    \A^^^^^^X^ 
On     the     other     hand,     several     ^^^fcl^ " 
important  advantages  would  be     ^^^^E;^  . 
gained  by  correcting  the  irregu-       ^^— 

larity.  The  wear  on  the  labial  faces  of  the  upper  incisors  would 
be  stopped.  The  corrected  articulation  would  assist  mastication, 
their  use  would  improve  the  nutrition  of  the  tissues  about  the 
loosened  teeth,  and  the  lower  incisors  would  have  more  support 
by  being  pressed  back  into  the  arch,  rather  than  outward  as  before. 
The  profile  would  be  improved  by  removing  the  sunken  appearance 
of  the  upper  lip,  and  the  prominence  of  the  lower  jaw  would  be 
lessened. 

After  carefully  considering  the  many  points  involved,  including 
the  age,  tendency  to  pyorrhoea,  and  the  conditions  enumerated,  it 


190 


INCISORS 


Fig.  179. 


Avas  recommended  tluat  the  diseased  gum  and  process  be  treated, 
and  that  the  upper  incisors  be  moved  outward  to  close  in  front  of 
the  lower  ones. 

An  appliance  was  made  of  German  silver  spring-wire,  anchored 
with  spring-clasp  attachments  to  a  tooth  on  either  side  of  the  arch 
(Fig.  179).    The  anchorage  on  the  left  side  was  to  the  first  molar  and 

on  the  right  to  the  second 
bicuspid  with  a  partial-clasp 
on  the  first  molar.  It  will 
be  observed  that  with  this 
arrangement  the  anchor- 
age did  not  come  in  contact 
with  or  interfere  with  the 
artificial  bicuspid  crowns. 

A  palatine  base- wire, No. 
14  gauge,  was  bent  to  fol- 
low the  contour  of  the  arch 
from  side  to  side,  crossing 
at  about  the  line  of  the 
mesial  surface  of  the  second  bicuspids.  One  end  of  the  base-wire  was 
bent  backward  nearly  to  a  right  angle,  and  the  other  bent  forward  to 
rest  on  the  partial-clasps  described.  A  spring- wire.  No.  19  gauge, 
was  formed  in  a  slight  curve  to  rest  on  the  lingual  side  of  the  incisors, 
reaching  from  the  cuspid  on  one  side  of  the  arch  to  the  cuspid  on 
the  other.  The  ends  of  the  wire  were  then  bent  with  a  small-sized 
clasp-bender  backward  and  again  forward,  forming  U-shaped  loops 
about  three-eighths  of  an  inch  long,  one  on  each  side,  opposite  the 
first  bicuspids.  The  loops  were  made  to  point  towards  the  median 
line  of  the  arch,  the  free  ends  of  the  spring  extending  backward  to 
cross  the  partial-clasps  with  the  ends  of  the  base-wire.  The  different 
parts  were  then  united  to  the  partial-clasps  with  soft  solder,  laying 
a  piece  of  solder  on  each  of  them  large  enough  to  do  all  the  soldering 
at  once,  using  muriate  of  zinc  as  a  flux,  and  melting  with  a  hot 
sold(.-ring  iron.  Tlie  parts  were  then  smoothed  with  a  carborundum 
stone  and  polished  the  same  as  a  metal  plate. 

In  this  case,  as  in  others  previously  described,  the  appliance  was 
not  arranged  to  open  the  bite  to  permit  the  instanding  teeth  to  be 
moved  outward.     It  is  not  n(;ces.sary  in  some  cases. 

A   platina-gold  collar,  No.  35    gauge,  with   a   lug  of  plate-metal 


UPPER   INCISORS,  TO   MOVE  OUTWARD 


191 


Fig.  180. 


soldered  to  the  lingual  side  and  resting  near  the  gum,  was  cemented 
to  each  of  the  lateral  incisors  to  retain  the  spring  of  the  appliance, 
and  when  the  regulating  was  about  one-half  completed  a  similar 
collar  was  cemented  to  one  of  the  central  incisors. 

The  action  of  the  appliance  was  controlled  by  opening  the  loops 
in  the  spring-wire.  The  regulating  was  begun  December  1,  1893, 
and  after  twenty-eight  days  the  upper  incisors  had  been  moved  out- 
ward to  close  in  a  normal  position  in  front  of  the  lower  incisors,  as 
seen  in  Fig.  180.  The  appliance,  without  change,  was  kept  in  posi- 
tion to  retain  the  teeth  until  January  18,  1894,  when  it  was  removed. 

It  will  be  remembered  that 
the  lower  incisors  were  loose 
from  pyorrhoea  alveolaris, 
one  of  them  especially  so. 
After  removing  the  appli- 
ance the  upper  incisors 
pressed  inward  on  the  lower 
incisors,  causing  them  to 
crimp ;  that  is,  some  of  them 
took  a  position  slightly  in 
advance     of    others.     This 

tendency  was  avoided  by  grooving  longitudinally  the  approximal  sur- 
faces of  the  loose  incisor  and  rounding  the  sides  of  the  two  adjoining 
teeth  to  fit  into  the  grooves,  and  flattening  slightly  the  approximal 
Fig.  181.  surfaces  of  some  of  the    otlier 

incisors.  By  this  arrangement 
both  the  upper  and  lower  in- 
cisors were  retained  in  position. 
At  this  writing  the  upper  in- 
cisors are  firm.  One  of  the  lower 
incisors  is  supported  with  a  re- 
taining device. 

Fig.   181   shows  the  form  of 

an  appliance  that  was  used  suc- 

-*  "'  cessfully  several   years  since  to 

correct  an  irregularity  for  a  lady  thirty-six  years  of  age.*    The  upper 

incisors  had  a  lingual  occlusion.     One  lateral  incisor,  bicuspid,  and 


*  Jackson,  Dental  Cosmos,  1890,  p.  877, 


192  INCISORS 

three  molars  of  the  upper  arch  were  missing,  some  of  them  having 
been  extracted  years  before  in  the  hope  of  correcting  the  irregularity, 
but  the  teeth  had  crowded  together  and  the  articulation  become  so 
changed  as  to  give  an  unpleasant  expression  to  the  features.  Besides 
this,  the  labial  faces  of  the  upper  incisors  were  becoming  worn. 
The  difficulty  that  is  experienced  of  moving  nearly  all  of  the  oral 
teeth  in  one  direction  was  very  marked  in  this  case. 

An  appliance  was  made  with  a  continuous  spring-clasp  for  each 
side  of  the  arch  to  encircle  the  teeth  back  of  the  incisors ;  a  slight 
separation  was  made  by  w'edging  in  front  of  the  cuspids  and  a  round 
iridio-platinum  wire  flattened  to  pass  into  the  space  on  either  side, 
extending  backward  and  following  the  line  of  the  gum  surrounding 
the  cuspid,  bicuspids,  and  first  molar.  This  was  supported  and  made 
to  clasp  the  teeth  firmly  by  connecting  the  two  sides  of  the  spring- 
clasps  with  wire  bars  passing  over  the  articulating  surface  at  the 
junction  of  the  teeth.  These  served  also  to  keep  the  appliance  from 
pressing  on  the  gum.  A  loop  or  eyelet  was  soldered  to  the  spring- 
clasp  opposite  the  lingual  surface  of  the  first  molar  on  each  side  of 
the  arch,  and  into  these  loops  were  hooked  the  ends  of  a  piano- 
wire  spring.  The  spring  was  semicircular  in  form  and  passed  just 
back  of  the  incisors,  with  the  ends  shaped  like  the  letter  S.  On  the 
incisors  were  placed  gold  collars  with  lugs  soldered  to  their  lingual 
surfaces,  in  order  to  hold  that  portion  of  the  spring  in  position. 

The  figure  shows  the  appliance  in  place  on  four  incisors  in  another 
completed  case  of  the  same  character.  Force  was  exerted  as  needed 
by  straightening  the  S-formed  loops  of  the  spring  a  little  at  a  time. 
The  incisors  were  moved  rapidly  outward.  When  sufficiently  so  the 
portion  of  the  sj^ring-clasp  in  front  of  each  of  tiie  cuspids  was  re- 
moved and  a  piece  of  piano-wire  soldered  to  tlie  original  si)ring-\vire 
and  extended  to  the  distal  side  of  the  cuspids,  l)y  the  application 
of  wliich  they  were  moved  forward. 

Another  spring  was  then  attached  to  the  original  one ;  the  front 
part  of  the  spring-clasp  was  cut  away  as  before  to  move  the  bicus- 
pids forward,  and  at  the  same  time  one  of  the  cuspids  was  rotated 
by  placing  on  it  a  collar  with  ;i  iiibe  soldered  to  its  lingual  surface  to 
hold  the  end  of  a  s{)ring  which  cxlendc.'d  to  tlie  opposite  side  of  the 
arcli  and  hooked  into  the  loop  in  the  spring-clasp. 

The  regulating  was  done  in  1888,  since  which  time  tlic  teeth  have 
been  examined  semiannually,  and  are  reinainiiig  in  good  position. 


UPPER   INCISORS,  TO   MOVE   OUTWARD— INCLINED   PLANE       193 

Inclined  Plane. — The  inclined  plane  for  moving  tlio  teeth  is  num- 
bered among  tlie  earlier  metliods  of  regulating.  It  was  described  by 
Catalan  in  1814,*  since  whicli  time  it  has  been  in  general  use,  being 
modified  and  improved  from  time  to  time  to  meet  the  conditions. 

Catalan  recommended  it  principally  for  moving  outward  instanding 
teeth  in  the  upper  arch,  fixing  it  to  the  teeth  of  the  lower  arch.  The 
appliance  was  made  by  shaping  a  long  narrow  band  of  plate-metal, 
either  gold  or  silver,  to  cross  the  labial  side  of  the  lower  teeth,  its 
ends  extending  back  usually  to  the  buccal  side  of  the  first  molars, 
where  short  pieces  of  plate  were  soldered  to  the  band  and  bent 
sharply  to  extend  onto  the  grinding  surface  to  prevent  it  from  slip- 
ping tow^ards  the  gum.  Similar  pieces  of  metal  were  soldered  to  the 
front  of  the  band,  extending  upward  and  backward  at  an  obtuse  angle 
for  forming  an  inclined  plane,  passing  behind  the  incisive  edge  of  each 
instanding  upper  tooth.  As  many  pieces  of  metal  were  used  as  there 
were  teeth  to  be  moved.  These  formed  smooth  planes,  descending 
downward  and  forward  over  the  lower  incisors  in  such  a  manner  as 
to  cause  the  upper  ones  to  slide  forward  w'hen  pressure  was  caused 
on  them  in  occlusion.  The  inner  ends  of  these  pieces  of  metal  were 
sustained  by  leaving  them  long  enough  to  be  bent  sharply  downward 
and  shaped  to  rest  on  the  lingual  side  of  the  incisors.  The  band 
was  fixed  to  the  teeth  with  ligatures. 

A  popular  and  effective  form  of  inclined  plane  was  described  a  few 
years  later,  and  it  is  still  recommended,  the  anchorage  being  more 
complete.  It  is  made  by  first  striking  up,  with  accurate  dies,  a  metal 
cap,  usually  passing  over  all  of  the  teeth  in  front  of  the  second 
molars.  When,  however,  the  shapes  of  the  teeth  are  favorable  it 
may  cover  a  less  number.  The  inclined  plane  is  made  by  bending 
a  narrow  strip  of  plate-metal  into  a  V-shape,  attaching  it  to  the  cap 
so  that  the  instanding  tooth  will  strike  in  front  of  the  elevation  in 
occlusion.  There  is  generally  a  considerable  pressure  on  the  appli- 
ance, and  the  latter  form,  covering  both  sides  of  the  teeth,  is  held 
more  securely,  and  is  less  liable  to  move  out  of  position. 

In  most  instances  the  appliance  can  be  removed  by  the  patient, 
but  it  can  be  fixed  to  the  teeth  by  passing  ligatures  between  them 
and  through  holes  on  either  side.     After  the  introduction  of  rubber 


*Fox  and   Harris,  1846,  p.  100;  Catalan,   Journal  General  de  Medecine,  de 
Chirurgie  et  de  Pharmacie,  January,  1814. 

13 


]  94  INCISORS 

vulcanite,  owing  to  its  ease  of  manipulation  and  the  close  adaptation 
secured,  it  was  extensively  used  for  making  inclined  planes.  In 
some  cases,  however,  the  rubber  has  proved  too  soft  for  the  incline, 
becoming  ineffective  on  account  of  the  wear.  When  rubber  is  used 
the  incline  may  be  covered  with  plate-metal. 

Devices  for  anchoring  the  inclined  plane  may  be  classed  as  the 
removable  and  the  fixed.  The  first  can  be  removed  by  the  patient 
for  cleansing.  The  fixed  include  those  that  are  cemented  to  the 
teeth  or  kept  in  place  by  ligatures  or  otherwise.  A  form  of  fixed 
inclined  plane  that  has  been  recommended  in  recent  years  for 
moving  outward  upper  incisors  is  made  by  fitting  a  half-round  wire 
to  the  labial  side  of  the  front  teeth,  with  the  ends  encircling  a  bicus- 
pid on  either  side  in  the  form  of  a  clasp  (in  cases  where  there  is 
a  space  back  of  them),  and  soldering  to  the  wire  in  the  front  part 
a  piece  of  plate-metal,  shaped  to  project  upward  and  backward  over 
the  lower  incisors.  This  forms  a  proper  incline  for  moving  the 
upper  incisors  outward.  The  inner  end  of  this  part  of  the  metal 
should  be  bent  downward  upon  itself  and  shaped  to  extend  onto  the 
lingual  side  of  the  lower  incisors  and  the  two  parts  soldered  to  form 
a  saddle.  It  is  desirable  to  have  the  saddle  of  the  appliance  rest  on 
several  teeth. 

Dr.  Guilford  has  described  a  form  of  fixed  inclined  plane  that  he 

devised  for  moving  inward  a  prominent  lower  tooth,  and  at  the  same 

time  moving  outward  an  instanding  upper  one  (Fig.  182).*     A  collar 

is  first  made  of  thin   platinum-plate  to  encircle  the 
Fig.  182. 

lower  incisor.     A  piece  of  gold-plate  is  then  bent  into 

a  V-shape  and  attached  to  the  collar  in  position  to 
extend  backward,  forming  an  incline,  with  one  arm 
of  the  metal  resting  on  the  labial  side  of  the  collar  and 
the  other  on  the  lingual,  to  which  they  are  strongly 
soldered.  The  device  is  cemeiitcKl  in  position  on  the 
tooth  with  zinc  phospliate,  having  the  cement  fill  all 
of  the  .space  under  the  incline  to  strengthen  it.  When  it  is  not  in- 
tended to  move  the  lower  incisor,  the  doctor  recommends  that  the 
appliance  bo  made  to  include  two  or  more  teeth  to  increase  the 
resistance. 

Several  years  since  I  devised  an  inclined  plane  of  the  form  shown 

*Guiiror.l,  Orllio.lontia,  ]8<)8,  p.  118. 


UPPER  INCISORS,  TO    MOVE   OUTWARD— INCLINED   PLANE       195 

in  Fig.  183.  It  is  strongly  retained,  and  can  be  removed  by  tlie 
operator  or  Ibe  patient  for  cleansing  wben  desired.  For  moving  ont- 
ward  an  upper  incisor  a  lin- 
gual base-wire  is  formed  to 
the  inner  curve  of  the  lower 
arch,  its  ends  anchored  by 
spring-clasp  attachments  to 
a  second  deciduous  molar, 
or  to  one  of  the  bicuspids  or 
permanent  molars  on  either 
side.  Apiece  of  plate-metal, 
usually  about  tlie  width  of 
three  of  the  teeth,  is  fitted 
above  the  base-wire,  ex- 
tending from  it  to  the  incisive  edge  like  a  continuous  partial-clasp^ 
being  located  opposite  the  tooth  to  be  moved.  The  incline  is  made 
with  a  lieavy  strip  of  plate-metal  of  the  width  and  length  required.  It 
should  be  fitted  close  to  the  labial  side  of  the  teeth,  with  the  part  that 
projects  above  the  incisive  edge  bent  backward  to  tlie  angle  desired 
for  tlie  incline  and  attached  with  solder  to  the  partial-clasp,  at  the 
same  time  attaching  tlie  partial-clasp  to  the  base-wire,  filling  all  the 
space  under  the  incline  with  solder.  With  this  construction  the  metal 
fits  closely  to  the  labial  and  lingual  sides  of  the  incisors,  assisting  the 
anchorage.  The  incline  can  readily  be  changed  by  dressing  it  away 
or  by  soldering  to  it  plate-metal  of  a  different  form. 

Some  of  the  objections  that  have  been  made  to  the  use  of  the 
inclined  plane  are  the  tenderness  that  is  often  engendered  by  the 
persistent  effort  in  closing  the  teeth,  sometimes  causing  severe  in- 
flammation ;  depression  of  the  tooth  in  the  socket ;  the  lack  of  cleanli- 
ness when  the  appliance  that  covers  the  teeth  is  held  with  ligatures  ; 
and  the  non-occlusion  of  other  teeth  than  those  being  operated  on, 
permitting  them  to  elongate  when  the  apparatus  is  continued  for  any 
length  of  time. 

Tliere  is  no  c|uestion  but  that  the  inclined  plane  for  moving  the 
teeth  is  superseded  by  better  methods,  although  tlie  application  of 
the  principle  may  be  made  serviceable  in  many  combinations.  (See 
Fig.  438.)  The  appliance  Avas  constructed  for  moving  into  line 
prominent  cuspids,  and  moving  outward  lateral  incisors  that  close 
considerably  inside  of  the  line  and  are  interlocked  by  the  centrals. 


196  INCISORS 

A  base-wire  was  formed  to  the  inner  circle  of  the  teeth,  with  the 
ends  anchored  to  a  molar  on  either  side.  The  anchorage  was 
strengthened  by  forming  pieces  of  plate-metal  to  cover  the  lingual 
side  of  the  lateral  incisors,  extending  to  the  incisive  edge,  the  ends 
being  soldered  to  the  base- wire  near  the  gum.  This  arrangement 
gives  the  base-wire  a  very  strong  anchorage.  The  inner  edges  of  the 
metals  were  curved  somewhat  over  the  mesial  surface  of  the  lateral 
incisors,  to  prevent  them  from  being  moved  farther  inward  and 
mesially  by  the  cuspids  when  pressure  was  caused  on  the  labial  side 
of  them  by  the  springs  provided  for  correcting  their  position.  After 
the  prominent  cuspids  were  moved  nearly  to  place  by  the  springs,  the 
ends  of  the  metals  resting  on  the  lateral  incisors  were  bent  forward, 
forming  inclines,  which  acted  like  inclined  planes  for  pressing  the 
lateral  incisors  outward,  and  at  the  same  time  the  inner  edges  of  the 
metals  were  curved  more  in  order  to  move  them  distally. 

In  Fig.  432  is  illustrated  a  similar  appliance  constructed  with  in- 
clined planes  for  moving  outward  instanding  lateral  incisors  in  a 
lower  jaw,  the  inclines  first  serving  to  assist  the  anchorage  for  moving 
a  prominent  cuspid  into  line.  It  will  readily  be  seen  that  the  at- 
tachment of  metal  to  a  base-wire  in  this  manner  can  be  utilized  in 
many  cases  for  anchorage,  and  later  serve  as  inclines  for  moving  teeth 
outward,  inward,  or  laterally,  as  may  be  desired. 

When  there  is  an  inharmonious  development  of  the  jaws,  with 
derangement  of  the  normal  occlusion,  as  wdien  the  cusps  of  the 
teeth  of  the  lower  jaw  close  considerably  back  of  the  proper  line, 
the  lower  jaw  can  sometimes  be  held  forward  until  the  tissues  adjust 
themselves  by  attaching  a  strong  inclined  plane  to  a  heavy  contoured 
gold  collar  or  a  crown,  cemented  to  an  upper  molar  on  each  side 
of  the  arch.  When  necessary  an  additional  collar  may  be  attached 
to  include  an  adjoining  tooth,  according  to  the  estimated  pressure 
to  be  caused  upon  them.  The  incline  should  be  made  similar  to 
the  appliance  described  by  Dr.  Guilford,  being  rather  sharp  and  i)ro- 
jecting  downward  to  close  back  of  the  last  erupted  lower  molar,  in 
order  to  hold  the  jaw  forward  and  prevent  the  improper  occlusion 
(Fig.  405). 

If  the  lower  molars  are  not  sufficiently  erupted  to  engage  with  the 
inclined  planes,  a  ])late  covering  the  palatine  arch,  with  a  heavy  metal 
or  vulcanite  incline  attached  to  its  anterior  portion  to  project  down- 
ward back  oi'  tlic  lower  incisors  when   in  normal  occlusion,  will   be 


UPPER  INCISORS,  TO  MOVE  OUTWARD— INCLINED  PLANE      197 

effective  in  most  cases  (Fig.  403).  Or  when  a  reverse  condition 
exists,  an  appliance  made  as  illustrated  in  Fig.  406  is  sometimes 
applicable. 

In  the  following  case  of  instanding  upper  incisors  and  protrusion 
of  the  lower  jaw  an  inclined  plane  proved  very  serviceable.     Miss  I., 

Fig.  184. 


aged  two  years  and  ten  months ;  prominent  lower  jaw,  with  the 
lower  incisors  and  cuspids  touching  the  gum  in  front  of  the  upper 
incisors  during  occlusion  (Fig.  184).  I  think  this  is  the  youngest  case 
on  record  where  an  operation  has  been  performed  for  the  correction 
of  a  similar  deformity. 

Accurate  impressions  were  taken  as  described  on  page  61.      An 
inclined  plane  was  made  of  two  pieces  of  plate-metal  (Fig.  185). 

Fig.  185. 


Wax  was  built  onto  the  lingual  side  of  a  model  of  the  lower  inci- 
sors and  cuspids,  the  upper  surface  of  the  wax  being  shaped  to  incline 
upward  and  backward  from  the  incisive  edge  of  these  teeth  to  an 
extent  and  at  an  angle  suitable  for  occlusion  with  the  teeth  of  the 
upper  arch.     An  impression  with  mouldine  was  then  taken  of  the 


198  INCISORS 

labial  side  of  the  teeth  and  the  upper  surface  of  the  wax.  From 
this  a  metal  die  and  counter-die  was  made,  which  was  used  to  strike 
up  a  plate  of  gold  to  form  the  front  part  of  the  incline  covering  the 
labial  side  of  the  lower  incisors  and  cuspids.  The  wax  was  then 
removed  and  the  metal  held  in  position  on  the  model  while  another 
impression  was  taken  with  mouldine  of  tlio  lingual  side  of  the  teeth 
and  tlie  jjrojecting  part  of  the  inclined  plane.  From  this  impression 
another  die  and  counter-die  were  made  for  striking  up  a  plate  to 
cover  the  lingual  side  of  the  teeth.  These  two  pieces  of  metal  were 
then  waxed  together  and  united  with  gold  solder,  forming  a  cap  and 
inclined  plane.  There  was  a  slight  interdental  space  between  the 
lower  central  incisors,  and  holes  were  made  in  each  side  of  the  cap 
part  of  the  inclined  plane  near  the  edge  corresponding  with  the  space 
between  the  incisors,  the  holes  being  made  on  a  line  with  the  margin 
of  the  gum.  A  small  copper  wire  was  passed  through  the  holes  and 
the  appliance  cemented  to  the  teeth  with  oxyphosphate.  Before  the 
cement  had  become  hardened  the  wire  ligature  was  drawn  tight,  the 
Fig.  186.  ends  twisted  and  shaped  so  as  not  to 

irritate  the  lip. 

The  device  was  applied  February 
10,  and  on  May  7  it  was  removed, 
the  teeth  articulating,  as  seen  in  Fig. 
186.  No  especial  discomfort  had  been 
experienced  by  the  patient  and  not 
a  tear  had  been  shed  in  the  office. 
During  the  last  seven  years  the  teeth 
of  the  patient  have  been  examined  several  times,  and  have  been 
found  in  good  position,  with  no  undue  prominence  of  the  lower  jaw. 
Opening  the  Bite. — Of  the  cases  of  irregularity  presented,  only 
a  small  jjercentage  require  the  appliance  to  be  arranged  to  open  the 
bite  iov  their  correction. 

When  the  jaws  are  at  rest  the  teeth  are  not  in  occlusion,  the  full 
occlusion  of  the  teeth  taking  place  only  at  the  time  of  mastication  of 
the  food,  during  the  act  of  swallowing,  during  extreme  muscular  or 
physical  strain,  while  enduring  pain,  and  at  times  during  sleep  when 
suffering  from  some  nervous  disorder.  The  o{)ening  of  the  bile  in 
any  manner  with  apparatus,  if  continued  for  a  considerable  time,  is 
likely  to  prove  detrimental  to  the  occlusion. 

Occasionally,  when  force  is  to  be  applied  for  the  regulation  of  teeth, 


UPPP:R   incisors,  to   move   OUT\VARD-OPENIN(i    lUTK        199 

it  is  necessary  to  open  the  bite,  as  where  the  upper  incisors  close 
deeply  back  of  the  lower  ones,  interlocking  them  ;  when  an  upper 
cuspid  lias  erui)led  inside  of  the  arch  in  such  a  manner  that  by 
opening  the  bite  its  movement  can  be  more  easily  and  quickly 
accomplislied  without  the  opposition  of  the  antagonizing  teeth  ;  and 
to  prevent  interlocking  of  the  teeth  when  a  chin-cap  or  equalizing 
device  is  applied  for  correcting  protrusion.  In  some  cases  of  short 
bite,  the  lips  are  naturally  pressed  togi^ther,  giving  an  appearance  of 
double  })rotrusion.  This  condition  is  usually  corrected  by  opening 
the  bite,  either  by  the  insertion  of  a  full  or  a  partial  jjlate  covering 
the  teeth,  or  by  adjusting  artificial  crowns  to  the  teeth. 

Opening  the  bite  has  been  used  to  advantage  in  cases  of  perice- 
mental inflammation,  where  the  teeth  were  extruded  and  the  closure 
of  the  jaws  painful. 

The  older  methods  employed  for  moving  the  incisors  outward  by 
the  use  of  the  wedge,  ligature,  etc.,  for  ex})ansion,  which  were  not 
so  certain  in  causing  their  movement,  made  il  more  necessary  that 
the  bite  be  opened,  and  for  tliis  purpose  blocks  of  gold  or  ivory,  gold 
caps,  and  sometimes  gold  plates,  were  fastened  to  the  occluding  sur- 
faces of  the  molars  or  bicuspids.  Later,  vulcanite  was  used  for  this 
purpose,  which  was  made  to  extend  over  the  grinding  surfaces  of 
the  teeth,  as  illustrated  in  the  Coflin  method  (Figs.  93  and  104). 

Appliances. — In  a  case  like  the  one  shown  in  Fig.  187,  where  the 
upper  incisors  have  a  lingual  occlusion,  an  appliance  may  be  made  to 

Fig.  187. 


move  them  outward,  and  at  the  same  time  to  open  the  bite  and  pre- 
vent the  lower  incisors  from  interfering  with  their  movement,  In'  first 
arranging  a  palatine  base-wire  to  cross  the  arch  from  side  to  side, 
with  the  ends  bent  sharply  backward  to  rest  on  the  partial-clasps 


200 


INCISORS 


(Fig.  188).     Spring-clasp  attachments  are  usually  fitted  to  the  first 
bicuspids  and  first  molars.     A  spring-wire  for  moving  the  incisors 


Fig.  188. 


outward  is  formed  to  the  lingual  side  of  them,  having  a  U-shaped 
loop  arranged  opposite  the  first  bicuspid  on  either  side  of  the  arch, 
its  ends  extending  backward  to  be  attached  with  solder  to  the 
anchorage  portion  with  the  ends  of  the  base-wire. 

For  opening  the  bite  a  thin  strip  of  platinoid,  German  silver,  or 
other  suitable  metal  (Fig.   189)  is  placed  on  the  model,  across  the 
Fig.  189.  grinding  surface  of  the  teeth  used  for  anchorage, 

from  front  to  back.     It  is  to  be  fitted  uito  the 
i.     .^^r^    //'        depressions   as  well  as  may  be  by  pressing  it 
with   an  instrument,  narrowing  the   ends  and 
passing  one  underneath  and  doubling  it  around 
/      r        1/  ^m  tlie  mesial  wire  of  the  spring-clasp  on  the  bi- 

cuspid, and  the  other  around  Hh^  distal  wire  of 
the  spring-clasp  on  the   molar.     Wax   is  then 
""^^^  built  up  on  this  part  and  the  appliance  inserted 

in  the  mouth  for  the  purpose  of  getting  a  bite,  at  the  same  time 
determining  how  much  the  upper  and  lower  arch  should  be  separated 
to  ])erniit  the  upper  incisors  to  be  moved  over  without  interference. 
Tlien  replace.'  the  appliance  on  the  model,  trim  the  edge  of  the  wax 
smooth,  and  jilaf-e  mouldine  over  it  to  form  a  matrix.  The  mouldine 
is  taken  off  to  remove  the  wax  and  replaced,  and  a  piece  of  block- 
tin,  soft  solder,  or  fusible  alloy  melted  in  an  iron  spoon  and  poured 
into  the  matrix.  This  forms  a  block  of  metal  on  the  appliance  in  the 
form  of  the  w^ax,  causing  a  good  articulation  wilh  llic  lower  Iceth. 
The  raised  jjart  can  b(!  built  ujj  in  a  few  iiK^iiK'nts  wilh  solder,  using 


Fig.  190. 


Fig.  191. 


UPPER   INCISORS,  TO   MOVE   OUTWARD— OPENING    BITE       201 


Fig.  192. 


the  soldering  iron,  or  a  bar  of  metal  soldered  on  and  dressed  to  form 
a  good  occlusion.  The  upper  incisors  are  moved  outward  with  the 
looped  spring  in  the  usual  manner,  and  when  they  have  passed 
sufficiently  in  front  of  the  lower  incisors  the  metal  is  dressed  away 
from  the  grinding  surface  from  time  to  time  as  much  as  the  position 
of  the  incisors  will  w'arrant  until  it  is  all  removed,  which  will  leave 
the  rest  of  the  appliance  like  an  ordinary  one.  The  same  appliance 
can  be  used  for  retaining  when  desired.  When  supplemental  force 
is  required  for  moving  the  incisors  outward,  an  apparatus  may  be 
applied  as  illustrated  in  Fig,  373. 

Fig.  190  shows  the  features,  before  regulation,  of  Miss  B.,  aged 
fourteen  years.  The  upper  arch  was  much  depressed,  w'ith  the  lip 
closing  back  of  the  line  of  the  lower  lip.  An  apparatus  similar  to 
the  one  described  in  Fig.  188  was  utilized  for  opening  the  bite  and 
moving  the  upper  incisors  outward.  The  improved  contour  of  the 
features  is  shown  in  Fig.  191. 

When  there  is  but  one  spring-clasp  attachment  on  either  side  of 
the  arch  for  anchorage  the  bite  may  be  opened  by  passing  a  piece  of 
thin  plate-metal,  with  the 
ends  narrowed,  underneath 
the  distal  and  mesial  arm  of 
the  spring-clasp,  as  shown  in 
Fig.  192,  and  by  flowing 
solder  in  a  sufficient  amount 
on  the  metal  \vith  the  sol- 
dering iron.  After  this  the 
solder  is  dressed  to  improve 
the  articulation.  The  form 
of  device  illustrated  in  the 
figure  can  be  utilized  for 
opening  the  bite  to  prevent 
occlusion    during   treatment 

for  pericemental  inflammation.  When  a  broader  occlusal  surface 
is  required  the  ends  of  the  metal  should  be  left  extending  onto  the 
adjoining  teeth,  and  solder  flowed  over  it  as  described. 

Fig.  109  illustrates  an  interesting  case  requiring  the  opening  of  the 
bite.  Metal  was  built  over  the  bicuspids,  cuspid,  and  incisors  on  one 
side  of  the  arch  to  favor  the  outward  movement  of  instanding  in- 
cisors and  cuspid  on  the  opposite  side  of  the  arch. 


202 


INCISORS 


The  practitioner  is  oecasionally  called  upon  (o  devise  a  method  for 
preventing  tlie  wear  or  breakage  of  the  teeth  from  gritting  them  at 
night.  The  apparatus  illustrated  in  Fig.  193  \vas  constructed  for 
that  purpose.    It  is  made  of  vulcanite,  passing  from  the  labial  to  the 

Fig.  193. 


hngual  side,  over  the  teeth  of  the  lower  arch,  and  retained  with 
spring-clasp  attachments  over  the  first  bicuspids  ;  the  upper  surface 
being  left  comparatively  smooth,  or  slightly  convex,  for  occlusion 
with  the  upper  teeth.  Sometimes  the  apparatus  is  applied  to  better 
advantage  in  the  upper  arcli  in  the  form  of  a  palatine  plate  with  a 
ledge  passing  over  the  occlusal  surfaces  of  the  teeth,  but  not  covering 
the  buccal  or  labial  faces. 

The  following  method  was  employed  some  few  years  ago  for  open- 
ing the  bite  and  moving  outward  uj^per  incisors  that  were  locked  in 
by  the  lower  incisors  (Fig.  194).     The  upper  incisors  closed  back  of 

Fig.  194. 


the  lower  incisors  a  considerable  dislance.  The  case  was  regulated 
with  an  old-style  vuh-anilo  plate,  which  would  hardly  be  recom- 
mended iir)W,  but  the  hislory  <'f)nlaiiis  some  imporlaiit  fcalurcs,  and 
will  be  described.* 


Jacksr)ii,  Dciilnl  Cosmos,  1887,  ]>.  377. 


UPPER   INCISORS,  TO   MOVE   OUTWARD— OPENING    BITE       203 


Fig.  196. 


The  plate  was  made  of  rubber  extending  over  the  molars  and  bi- 
cuspids to  tlie  gum  line  for  anchorage,  with  silver  screws  inserted  in 
the  rubber  bacic  of  the  incisors  (Fig.  195).  The  threaded  holes  in 
the  rubber  for  the  screws  were  made  by  drilling  the  lioles  a  little 
smaller  than  the  size  of  the 
screws  to  be  used.  A  little  wax 
was  put  into  the  holes ;  tlu' 
screws  were  warmed  and  turned 
into  the  openings.  The  heat 
from  the  metal  softened  the  rub- 
ber and  made  a  good  thread. 
As  the  teeth  moved  outward, 
leaving  the  screws  long,  they 
were  bent  so  as  to  rest  near  the  necks  of  the  teeth,  and  the  pressure 
was  thus  kept  at  the  right  point ;  a  slight  turn  of  the  screws  caused 
pressure  at  the  distal  or  mesial  edge,  rotating  the  tooth  as  desired. 

It  was  not  difficult  to  bring  the  upper  incisors  into  proper  position, 
as  seen  in  Fig.  196,  but  when  the  regulating  seemed  complete,  and 

the  teeth  had  been  retained 
several  weeks,  a  serious  com- 
plication began  to  arise,  and  one 
that  could  not  be  corrected,  as 
the  patient  would  not  submit  to 
Ihe  treatment  suggested.  This 
•  omplication  is  one  that  is  often 
met  with,  though  we  hear  very 
little  about  the  real  cause.  The 
father  of  the  patient  had  a  very  ])rominent  lower  jaw,  and  it  was 
found  that  the  lower  jaw  of  the  patient  was  constantly  moving 
forward  on  the  bite.  At  a  later  date  the  jaw  was  still  continuing  to 
grow  forward.  Contrary  to  the  general  rule,  it  was  taking  the  form 
that  is  found  at  birth  and  extreme  old  age.  In  other  words,  there 
was  no  distinct  angle,  as  at  the  age  of  puberty  or  on  approaching 
adult  life.  The  upper  incisors  were  moved  outward  again,  and  there 
still  being  a  constant  forward  growth  of  the  lower  jaw,  all  of  the  teeth 
in  front  of  the  second  bicuspids  were  moved  outward  a  third  time  by 
a  system  of  wedging  (Fig.  197).  A  plate  was  applied  to  retain  the 
teeth,  and  still  the  lower  jaw  became  more  prominent,  causing  lack 
of  anterior  occlusion. 


204 


INCISORS 


A  chin-retractor  Avas  recommended  early  in  this  case,  which  would 
have  arrested  the  advance  of  the  lower  jaw,  but  the  parents  were 
not  willing  to  permit  its  use.  At  the  present  writing  the  upper 
incisors  have  retained  their  ])osition  well,  wdth   their  edges  above 

Fig.  197. 


those  of  the  lower,  but  the  lower  jaw  has  become  very  prominent, 
and  the  incisors  are  crimped  and  tip  considerably  backward.  The 
latter  change  is  due  to  the  tension  of  the  lower  lip. 

When  there  is  a  tendency  for  the  lower  jaw  to  advance  in  this 
manner,  an  equalizing  device  or  a  chin-cap  should  always  be  applied 
in  the  early  stages,  as  these  conditions  are  progressive,  and  its  use 
persisted  in  as  long  as  required. 

Plates. — In  Fig.  1 98  is  presented  the  case  of  a  boy  aged  nine  years, 
whose  rigiit  upper  lateral  incisor  was  erupted  inside  of  the  circle  of 

Fig.  198. 


the  arch  back  of  the  central  incisor  and  deciduous  cuspid,  with  the 
space  nearly  closed.  The  first  bicuspids  were  erupted.  The  second 
deciduous  molars  were  still  in  place. 

The  practice  of  extracting  a  deciduous  cuspid  to  give  room  for  a 
crowded  permanent  incisor  is  not  a  good  one.    The  deciduous  cuspid 


UPPER  INCISORS,  TO  MOVE  OUTWARD  205 

should  be  relaiiied  to  koep  the  space  necessary  for  the  eruption  of 
the  permanent  cuspid  in  the  circle.  The  permanent  incisors  are 
broader  than  the  deciduous  ones,  and  are  likely  to  be  erupted  in  an 
irregular  position  if  not  accompanied  with  harmonious  development 
of  the  premaxillary  bone.  The  antero-posterior  diameter  of  the 
deciduous  molars  is  greater  than  that  of  their  successors,  the  bicus- 
pids. The  combined  measurement  of  the  deciduous  molars  and 
cuspid  is  as  much  as  or  more  than  that  of  the  permanent  cuspid  and 
bicuspids,  and  if  these  deciduous  teeth  are  jireserved  the  permanent 
ones  usually  have  sufficient  room  for  proper  eruption  in  the  circle. 

To  force  the  malerupted  lateral  incisor  into  its  proper  place 
between  the  central  incisor  and  deciduous  cuspid  it  was  necessary 
to  expand  the  arch.  A  split  vulcanite  plate  with  springs  was  used, 
the  lateral  halves  being  joined  by  a  U-shaped  spring  and  the  plate 
retained   by  wire-clasps  (Fig.   199).     The    plate  was   separated  by 

Fig.  199. 


dividing  it  with  a  fine  saw  from  where  it  came  in  contact  with  tlie 
irregular  lateral  in  a  curve  backward  along  the  median  line.  The 
advantage  of  this  form  of  separation  is  apparent. 

The  part  of  the  plate  covering  the  left  side  of  the  palatine  arch  was 
attached  to  all  of  the  teeth  around  to  the  irregular  lateral  incisor  by 
the  help  of  the  wire-clasps,  and  acted  as  an  anchorage  for  moving 
outward  all  of  the  teeth  on  the  right  side.  One  end  of  a  spring-wire, 
in  the  form  of  three  loops,  was  fixed  to  the  left  section  of  the  plate, 
the  other  end  resting  under  a  lug  on  a  collar  cemented  to  the  irregu- 
lar lateral  incisor.  As  the  loops  of  the  springs  were  opened  it  sepa- 
rated the  sections  of  the  plate,  expanding  the  arch,  and  at  the  same 


206 


IN'CISORS 


time  the  lateral  incisor  was  moved  outward  to  its  proper  place.  After 
the  regulating  was  completed  the  teeth  were  retained  with  the  device 
illustrated  in  Fig.  496. 

In  Fig.  200  is  shown  the  case  of  Miss  H.  The  upper  lateral  in- 
cisors were  erupted  considerably  inside  of  the  circle  of  the  arch, 

witli  tlie  cuspids  directly  in 
front  of  them.  The  space 
between  the  central  incisors 
and  first  bicuspids  was  only 
sufliciontly  broad  to  admit 
of  one  tooth  on  each  side, 
either  the  cuspid  or  lateral 
incisor.  The  central  inci- 
sors, bicuspids,  and  molars 
articulated  properly  with 
those  of  the  lower  arch.  It 
was  not  practicable  to  ex- 
pand the  arch  sufficiently  to 
let  the  cuspids  and  lateral 
incisors  into  proper  position.  The  cuspids  could  be  moved  into 
the  spaces  and  the  circle  of  the  arch  preserved,  but  the  arch  would 
then  appear  too  narrow,  owing  to  the  points  of  the  cuspids  show- 
ing, with  only  two  teeth  between  them,  when  naturally  there  are 
four. 

The  important  reasons  for  retaining  the  cuspids  are  their  usual  good 
structure,  great  strength,  and  the  preservation  of  the  canine  ridge, 
which  is  lost  by  the  absor[)tion  of  the  process  when  the  root  is 
removed;  therefore  the  cuspid  should  always  be  i)reserved  unless 
some  condition  necessitates  its  removal. 

The  loss  of  the  canine  ridge  detracts  materially  from  the  character 
of  the  features.  It  is  more  important  to  be  preserved  in  the  case  of 
a  female  than  a  male,  as  in  the  latter  a  defect  in  the  contour  of  the 
lip  can  be  covered  by  a  moustache. 

However,  from  careful  examination  in  tiiis  case  it  was  seen  that 
the  buccal  and  mesial  faces  of  the  first  bicuspids  closely  imitated 
the  appearance  of  the  cuspids,  and  that  the  lateral  incisors  if  moved 
outward  would  fill  the  sjjacf.'S  so  thoroughly  and  improve  the  general 
effect  tliat  it  was  ddermiiK'd  to  sacrifice  the  cuspids  and  move  the 
laterals  outward,  and  thus  maintain  the  circle  of  the  arch  (Fig.  201). 


UPPER   TNCISORS,  TO   MOVE   OUTWARD 


207 


The  cuspids  were  extracted  and  a  jjlaliiia-j^'old  collar  with  a  lug  on 

the  lingual  side  was  cemented  to  eacli  of  the  laterals  for  supporting 

the  end  of  a  spring.     A  vulcanite  plate  was  formed  covering  the 

palatine  arch,  with  a  suction 

f  ,  .p,  .  Fig.  201. 

for    anchorage.       11  le    arch 

was  rather  deep,  the    plate 

had  a  good  fil,  and  no  fiu'- 

tlier  retaining  was  necessary. 

The  sides  of  the  front  part 

of  the    plate    were    dressed 

away    to    permit    the    free 

action  of  tlie  springs.     These 

Avere  arranged  in  the  distal 

part  of   the    plate  and    ex- 
tended forward  in  a  double 

curve,    one   on    eitlier   side, 

with  the  ends  resting  underneatli  the  lugs.     Force  was  caused  by 

bending  outward  tlie  ends  of  the  springs.     The  result  proved  very 

satisfactory. 

Fig.  202  illustrates  the  lower  arch  of  the  same  case.     One  of  the 

incisors  had  been   removed    and  the   three    remaining  ones    were 

bunched  together,  the  space 
between  the  cuspids  being 
too  narrow  for  their  admis- 
sion. Owing  to  the  close 
occlusion,  it  was  not  con- 
sidered practicable  to  in- 
crease the  distance  between 
the  cuspids  sufficiently  to  ad- 
mit tiie  irregular  teeth.  A 
moderately  satisfactory  re- 
sult was  attained  by  the  ex- 
traction of  one  of  the  remain- 
ing incisors  and  moving  the 

others  forward,  which  fdled  the  space  between  the  cuspids.     Tlie 

cuspids  were   then    dressed   so  as  to   conform  more  nearly  to  the 

shape  of  the  incisors. 

Fig.  203  represents  the  condition  of  the  teeth  of  Miss  S.,  aged  four- 
teen years  when  presented  for  treatment.     Within  the  year  she  had 


208 


INCISORS 


worn  a  regulating  appliance  retained  with  ligatures  for  several  months 
under  tlie  direction  of  another  practitioner. 

The  upper  central  incisors  closed  in  correct  position  over  the  lower 
ones,  but  the  lateral  incisors  had  receded  considerably  and  closed 
FiG  203.  inside  of  the  lower  arch.     The 

cuspids  were  too  prominent, 
with  insufficient  space  for  their 
admission.  The  pulps  of  both 
first  permanent  molars  were 
dead  and  the  crowns  so  badly 
decayed  that  it  was  decided  to 
extract  them. 

A  plate  as  seen  in  Fig.  204 
was  inserted.     It  was  made  of 
vulcanite     and     retained    with 
wire-clasps.     Two  of  them  ex- 
■"'-'  tended    from    the    distal    part, 

one  on  either  side  to  encircle  each  of  the  second  molars,  and  two 
spring-wires  shaped  with  a  slight  curve  extended  from  the  plate  out- 
ward to  rest  on  the  mesial  side  of  the  first  bicuspids.  The  latter 
assisted  in  retaining  the  plate  and  at  the  same  time  were  utilized 
for  moving  the  bicuspids  backward.  Two  other  springs  for  moving 
the  lateral  incisors  outward  were 
anchored  in  the  front  part  of  the 
plate  just  back  of  the  central  in- 
cisors, each  extending  forward  in 
the  form  of  a  loop  and  tlien  back- 
ward and  outward  in  the  shape 
of  the  letter  S ;  the  ends  were 
made  to  pass  under  lugs  on  the 
lingual  side  of  collars  cemented 
to  the  laterals. 

The  regulation  was  Ijeguii  by 
bending  the  ends  of  these  springs  forward  and  at  the  same  time 
bending  the  side-springs  slightly  so  as  to  cause  pressure  on  the 
mesial  surface  of  the  bicuspids  for  moving  them  backward.  The 
change  of  position  of  the  latter  increased  the  space  for  the  cuspids. 

Almost  any  form  of  sjjring  that  can  be  used   with  a  base-wire 
device  can  be  used  to  advantage  when  attached  in  a  vulcanite  plate. 


Fig.  204. 


UPPER   INCISORS,  TO   MO\'E   OUTWARD  209 

Fig.  205  illustrates  a  iiu'tliod  oiuployed  for  moving  outward  incisors 
by  a  looped  spring  attached  in  a  plate  for  anchorage.  The  spring- 
wire  is  formed  to  the  lingual  contour  of  the  teeth,  with  a  U-shaped 
loop  formed  in  it  on  either  side  opposite  the  first  bicuspids,  pointing 

Fig.  205. 


towards  the  median  line,  and  the  ends  of  the  wire  curved  backward, 
flattened,  and  extended  into  the  vulcanite.  The  wire  is  less  liable  to 
break  at  the  surface  of  the  plate  if  the  end  of  the  part  of  the  spring 
that  enters  it  is  flattened,  leaving  the  wire  round  where  it  emerges 
from  the  rubber.  The  plate  should  be  retained  with  wire-clasps 
extending  around  one  or  more  of  the  molars  or  bicuspids  on  either 
side.  When  there  is  no  space  between  the  teeth  the  wire-clasps  can 
be  extended  over  the  arch  and  shaped  to  cross  the  buccal  side. 

In  using  the  looped  form  of  spring  it  is  often  advisable  to  cut  away 
a  portion  of  the  rubber  near  the  loops,  so  that  they  can  be  bent  more 
easily  for  causing  action.  A  collar  with  a  lug  on  the  lingual  side  can 
be  cemented  to  two  or  more  of  the  incisors  for  retaining  the  spring. 

In  making  the  plate  the  flattened  ends  of  the  springs  and  clasps 
should  be  embedded  in  a  try-plate,  and  pieces  of  binding  wire  put 
around  the  looped  spring  in  several  places  and  twisted  lightly,  their 
ends  separated  and  left  projecting  upward  to  hold  the  spring  firmly 
in  the  plaster  in  the  upper  half  of  the  flask  when  separated  for 
packing. 

A  device  tliat  iias  been  recommended  for  moving  outward  an  in- 
standing  incisor,  is  made  by  cementing  to  the  incisor  to  be  moved 
a  collar  having  a  screw-post  projecting  from  the  labial  side  of  it,  and 
arranging  a  curved  piece  of  flat  spring-metal  with  a  hole  m  the  centre 

14 


210 


INCISORS 


Fig.  206. 


to  pass  over  the  post,  shaping  the  ends  to  rest  on  the  labial  side  of 
the  adjoining  teeth  (Fig.  206).  To  give  the  desired  pressure  a 
threaded  nut  is  then  run  on  to  the  screw-post,  with  a  watch-key 

fitted  as  a  wrench  to  turn 
the  nut.  If  the  incisor  is 
considerably  back  of  the 
adjoining  teeth,  and  space 
is  insufficient,  the  curved 
bar  should  be  reversed, 
having  the  convex  side 
towards  the  incisor  to  be 
moved.  Pressure  caused 
by  the  bar  in  this  position 
will  tend  to  drive  the 
adjoining  teeth  laterally, 
broadening  the  space  and 
at  the  same  time  allowing  the  incisor  to  be  moved  outward,  after 
which  the  bar  should  be  changed,  placing  the  concave  side  inward. 

It  has  been  suggested  that  two  or  more  teeth  can  be  moved  out- 
ward in  a  similar  manner.  Dr.  Eugene  H.  Smith*  recommends  in 
some  cases  that  the  screw-post  be  attached  to  the  tooth  Avithout  the 
use  of  a  collar  by  soldering  it  to  the  centre  of  a  piece  of  gold  plate, 
the  latter  being  fitted  to  the  labial  side  of  the  irregular  tooth  and  held 
in  that  position  with  a  ligature  wound  around  it  from  the  neck  to 
near  the  incisive  edge. 

Some  operators,  notably  Dr.  Byrnes,!  have  used  a  narrow  strip 
of  elastic  metal,  as  spring-gold,  or  a  small-sized  clock-spring,  for 
moving  outward  instanding  incisors,  passing  the  spring  around  the 
irregular  tooth  and  shaping  the  ends  to  press  on  the  labial  sides  of 
the  adjoining  ones.  Tlie  tension  of  the  spring  tends  to  broaden  the 
space  and  at  the  same  time  move  the  tooth  outward. 

In  1541  Egenolff  explained  that  irregular  teetli  could  be  moved 
to  correct  position  by  pressure  with  the  fingers. | 

Persistent  force  thus  applied  where  the  teeth  are  erupting  will  often 
prove  efficacious  in  correcting  their  position,  and  in  some  cases  even 


*  Srnilh,  International  Dental  Journal,  1893,  p.  846. 

t  Byrnes.  D<-ntal  Cosmos,  1886,  p.  278. 

I  Et'enolCf,  Translation,  Dental  Cosmos,  1887,  p.  3. 


UPPER   INCISORS,  TO  MOVE  OUTWARD  211 

though  they  are  considerably  irregular.  (See  Figs.  290  and  291.) 
In  occasional  cases  an  incisor  erupting  considerably  inside  of  the  arch 
can  be  moved  outward  in  this  manner. 

Later  was  described  a  method  of  moving  upper  incisors  outward 
by  the  use  of  a  thin  piece  of  wood,  placing  it  between  the  upper 
and  lower  incisors  at  an  angle  to  cause  an  inclined  plane,  having  the 
patient  bite  forcibly  against  il,  and  holding  it  in  that  position  as  much 
of  the  time  as  possible.*  A  thin  piece  of  metal,  similar  to  the  blade 
of  a  narrow  case-knife,  is  probably  more  effective. 

As  has  been  stated,  Catalan  recommended  the  use  of  the  inclined 
plane  in  1814.t 

Another  method  was  to  fit  a  block  of  ivory  to  tlie  roof  of  the 
mouth,  tied  to  the  side  teeth, :J:  the  incisors  being  forced  outward  by 
placing  wedges  of  wood  or  other  material  between  them  and  the 
ivory  ;  in  some  cases  opening  the  bite  to  permit  the  instanding  upper 
incisor  to  pass  over  the  lower  ones  by  attaching  a  block  of  ivory, 
gold,  or  wood  between  the  upper  and  lower  molars. 

Many  forms  of  long  bars  have  been  described  for  moving  the  in- 
cisors outward.  The  earlier  ones  were  made  with  a  strip  of  metal, 
shaped  as  nearly  as  might  be  into  the  curve  it  was  desired  the  teeth 
should  assume  when  regulated,  passing  on  the  labial  side  of  the  an- 
terior teeth  and  crossing  the  buccal  surface  of  the  first  and  in  some 
cases  the  second  molars.  The  bar  was  sometimes  punctured  with 
holes,  or  had  hooks  attached  in  different  parts  to  accommodate  liga- 
tures to  pass  from  the  bar  around  the  teeth,  both  for  the  purpose  of 
anchorage  and  for  moving  the  irregular  teeth  into  line.  In  more  recent 
years  half-round  or  round  wire  has  been  utilized  for  this  purpose. 

Several  methods  have  been  devised  for  anchoring  the  ends  of  the 
bar  to  the  molars  and  bicuspids,  the  earlier  procedure  being  the 
attachment  of  pieces  of  plate-metal  to  the  bar,  so  shaped  that  when 
bent  at  a  right  angle  they  would  rest  on  the  grinding  surface  of  the 
molars.  Also  the  bar  was  attached  to  the  teeth  with  metal  clasps, 
and  held  in  position  with  ligatures  and  bands  extending  over  the 
teeth,  and  by  soldering  the  ends  of  the  bar  to  a  metal  plate. 

In  cases  where  the  incisors  were  to  be  moved  outward  the  ends  of 


*  Sigiaund,  1825,  p.  17. 

t  Fox  and  Harris,  1846,  p.  100. 

X  Tomes,  American  Journal  of  Dental  Science,  1848,  p.  52. 


2]  2  INCISORS 

the  bar  were  attaclied  to  clasps  or  bands  for  anchorage  in  position  to 
permit  tlie  anterior  portion  of  the  bar  to  rest  sufficiently  in  front  of 
tlie  incisors  to  allow  them  to  be  drawn  outward  into  the  circle  by 
ligatures  that  were  passed  around  them  and  the  bar,  the  spring  of 
the  bar  causing  their  movement. 

Since  the  introduction  in  1839  of  rubber  vulcanite  for  anchorage 
many  forms  of  attachment  have  been  recommended  for  holding  the 
ends  of  metal  bars  shaped  to  pass  in  front  of  the  incisors  for  the 
purpose  of  drawing  them  outward,  they  being  attached  to  the  bar 
with  ligatures.  Dr.  Kingsley  has  described  such  an  appliance  in  his 
work  on  Orthodontia,  using  the  cord  or  rubber  ligatures. 

In  some  instances  a  rubber  plate  capping  the  back  teeth  witli  a 
vulcanite  band  extending  in  front  of  the  incisors  has  been  constructed, 
holes  being  made  in  the  band  opposite  the  incisors  for  ligatures  made 
from  rubber  tubing. 

A  similar  rubber  plate  without  the  band  has  been  utilized  for 
moving  the  upper  incisors  outward  by  a  system  of  Avedging,  the 
plate  forming  the  anchorage ;  the  anterior  part  being  made  thick, 
sometimes  shaped  hke  a  dovetail  for  holding  wedges  of  soft  rubber, 
etc.  In  other  cases,  holes  are  drilled  for  the  insertion  of  wood  points 
or  metal  screws.  The  latter  appliances  are  effectual,  but  they  are 
inclined  to  rest  on  the  prominence  of  the  incisors  and  to  de])ress 
them,  as  by  the  action  of  an  inclined  plane. 

Plates  with  long  bands  and  screw-nuts  are  being  used  for  moving 
outward  and  inward  the  incisor  teeth.  The  bands  are  attached  to 
the  plate  by  passing  through  projections  or  staples  on  the  buccal 
side,  and  the  bands  are  ligated  to  the  teetli. 

Collars  cemented  or  bolted  to  the  molars  or  bicuspids  for  holding 
jack-screws,  or  with  tubes  attached  for  holding  the  ends  of  long 
bands,  are  also  being  used  extensively  ;  they  are  recommended  espe- 
cially by  Drs.  Farrar  and  Angle.  The  long  bands  are  provided  with 
thread  and  nut  for  drawing  them  forward  or  backward. 

Improving'  the  Contour  of  the  Arch  by  the  Use  of  Crowns. — 
Soon  after  the  introduction  of  the  crown  constructed  with  the  gold 
collar,  post,  and  porcelain  front,  as  described  by  Richmond,  I  utilized 
the  iiii'tli(Ml  for  a  case  of  irregularity  of  an  instanding  incisor. 

A  gold  crown  was  tilted  to  the  tooth  with  a  porcelain  attached; 
this  was  placed  far  enough  forward  to  form  a  good  contour  with  the 
adjoining  teeth.     The  space  near  the  gum  was  lilled   In  with  gold; 


UPPER   INCISORS,  TO   MOVE   OUTWARD  213 

leaving  a  sulcus  back  of  the  porcelain  sufficiently  deep  to  let  the 
lower  teetli  occlude  properly. 

This  method  was  adopted  for  improving  the  contour  of  the  teeth 
in  the  case  of  Mrs.  H.,  whose  teeth  were  very  irregular,  several  of 
them,  including  the  incisors,  cuspids,  and  bicuspids,  closing  consider- 
ably inside  of  the  proper  line.  The  teeth  were  defective,  and  not 
worth  moving  to  correct  position. 

The  iiatient  at  first  wanted  to  have  tlie  incisors  extracted  and  a 
plate  inserted,  but  was  pleased  with  the  method  suggested.  There 
were  in  all  five  crowns  inserted.  One  of  the  teeth  was  so  far  inside 
of  the  arch  that  the  space  between  it  and  ttie  porcelain  front  was 
more  than  the  width  of  the  tooth,  the  intervening  space  being  spanned 
with  a  bar  of  gold  next  the  gum.  The  crowns  have  been  worn  over 
twenty  years,  and  are  still  doing  good  service. 

Moving-  Roots  for  Crowning. — The  improvement  of  the  position 
of  a  malposed  root  for  the  attachment  of  an  artificial  crown  is  occa- 
sionally required. 

Several  methods  have  been  devised  for  this  purpose,  most  of  them 
being  dependent  on  a  post  placed  in  the  root,  anchored  in  the  nerve- 
canal  with  cement  phosphate  ;  or  by  turning  into  it  a  screw-post,  to 
which  ligatures  or  rubber  bands  may  be  attached  extending  over  the 
adjoining  teeth  for  causing  pressure  to  move  the  root  laterally. 

A  spring  in  the  form  of  a  coil  has  been  used  to  advantage  for 
moving  roots  of  teeth  in  different  directions. 

A  simple  method  of  attaching  a  spring  has  been  described  by  Dr. 
Silleto.*  He  bends  the  wire  into  a  coil  of  two  or  three  turns  of 
suitable  size  to  pass  over  a  post  inserted  in  the  root,  the  ends  of  the 
wire  being  shaped  to  press  on  the  sides  of  the  adjoining  teeth  in  such 
position  as  to  give  the  required  pressure.  A  similar  form  of  spring 
has  been  recommended  by  Dr.  Siegfried  t  for  moving  teeth  outward 
and  inward  in  the  arch  by  fastening  the  coil  to  the  labial  or  lingual 
side  of  the  teeth,  its  ends  bearing  on  the  adjoining  ones. 

*  Silleto,  Ohio  Dental  Journal.  1894,  p.  2. 
f  Siegfried,  Dental  Cosmos,  1896,  p.  497. 


CHAPTER  XII 


INCISORS,   TO    MOVE    INWARD    OR    LINGUALLY 

Lower  Incisors,  to  move  Inward. — Cases  requiring  tlie  inward 
movement  of  the  lower  incisors  are  comparatively  few.  The  upper 
incisors,  on  the  other  hand,  often  take  a  position  back  of  the  lower 
ones  in  the  process  of  eruption,  necessitating  their  outward  move- 
ment to  get  normal  occlusion. 

When  the  lower  incisors  are  too  prominent  they  are  usually  accom-' 
panied  with  a  degree  of  prognathism  or  prominence  of  the  lower 
jaw.  If  their  irregularity  is  not  very  marked,  requiring  them  only 
to  be  moved  inward  with  the  process,  it  can  be  easily  accomplished 
by  continued  pressure  on  the  labial  side  of  the  teeth,  but  when  there 
is  a  prognathous  jaw  their  correction  is  more  difficult,  and  an  equal- 
izing device  or  a  combined  apparatus  with  chin-cap  is  employed. 
Where  there  is  protrusion  of  the  lower  incisors,  and  they  are  crowded 
in  the  arch,  space  for  their  inward  movement  can  be  made  only 
by  lateral  expansion  or  by  the  extraction  of  a  tooth  on  either  side ; 
otherwise  the  movement  of  the  whole  arch  of  teeth  backward  with 

the  process  is  required,  or 

Fif    207 

even  the  backward  move- 
ment of  the  jaw  proper. 
Fig.  207  shows  the  form 
of  an  appliance  that  has 
been  used  for  moving  in- 
ward the  incisors  and  cus- 
pids at  one  time,  the  first 
bicuspids     having     been 
extracted.       T\\e    device 
is   equally  ap])hcable   for 
moving    a     less    number 
of  lecU).     The  anchorage 
consists    of    four    molars 
and  two  bicuspids.     W'lien  Hk;  wisdom-teeth  are  erupted  they  should 
be  included  in   the  anchorage.     A  lingual  base-wire,  about  No.  13 
gauge,  is  bent  to  conform  lo  llio  inner  curve  of  the  arch,  being  placed 
214 


LOWER   INCISORS,  TO   MOW.    LWVARI) 


215 


far  enoLigli  back  of  the  incisors  to  porniit  tlieir  niovcmcnl,  its  ends 
ancliored  witli  spring-clasp  attacliuients  to  the  first  molars,  jiartial- 
clasps  on  the  adjoining  teetli,  and  wire-clasps  extending  bacicward 
to  the  distal  sid(»  of  the  second  molars.  If  all  of  tlie  teeth  are  erupted, 
spring-clasp  attaclnnents  should  be  i)laced  over  the  second  bicuspids 
and  second  molars. 

Two  long  curved  finger-springs  are  attached  to  the  base-wire  and 
partial-clasps,  one  on  either  side  of  the  arch,  extending  through  the 
space  caused  by  extraction,  just  in  front  of  the  second  bicuspids,  to 
tlie  buccal  side,  and  bent  forward,  following  the  labial  curve  of  the 
incisors  and  cuspids  ;  they  should  pass  each  other  at  the  median  line. 
Tiie  variation  of  pressure  is  caused  by  shaping  the  springs  to  impinge 
upon  the  teetli  it  is  desired  to  move,  usually  first  causing  force  on 
tliose  at  the  median  line.  When  there  is  sufficient  interdental  space 
between  the  front  teeth  to  permit  of  their  backward  movement  ex- 
traction is  not  required,  and  this  form  of  spring  may  be  shaped  to 
extend  from  the  base-wire  over  the  arcli  from  the  labial  to  tlie  lingual 
side  at  the  junction  of  two  of  the  teetli,  projecting  forward  in  the 
same  manner.  When  the  teeth  used  for  anchorage  are  inclined  to 
move  forward,  or  when  more  pressure  is  required,  supplemental 
force,  as  with  infralabial  bar  or  a  cross-bar,  should  be  employed. 

In  Fig.  208  is  shown  another  form  of  appliance  for  moving  back- 
ward at  one  time  the  six  anterior  teeth.     A  lingual  base-wire  located 

Fig.  208. 


with  a  space  between  it  and  the  teeth  to  be  moved  is  anchored  to  the 
molars  and  bicuspids  as  described.     A  spring- wire,  about  No.   19 


216  INCISORS 

gauge,  is  bent  into  a  semicircle,  either  end  terminating  in  a  U-shaped 
loop  about  one-fourth  of  an  inch  long,  the  spring  conforming  to  the 
labial  faces  of  the  incisors  and  cuspids  near  the  neck.  Its  loops  pass 
back  of  the  cuspids  to  the  lingual  side,  resting  between  the  base- wire 
and  the  gum ;  the  ends  are  soldered  to  the  anchorage  portion  with 
the  ends  of  the  base-wire  and  spring-clasps.  The  desired  force  is 
applied  by  closing  the  loops  of  the  spring  a  little  from  time  to  time. 

When  there  are  no  interdental  spaces  between  the  teeth  to  be 
moved  the  curve  of  the  spring  should  be  such  as  to  leave  a  narrow 
space  between  it  and  the  distal  surface  of  the  cuspids  to  prevent  the 
teeth  being  wedged  or  crimped  together  during  their  movement. 
Closing  the  loops  in  the  spring  first  causes  more  inward  pressure  on 
the  cuspids  than  the  incisors.  The  principal  force  being  thus  first 
applied  to  two  teeth  only,  the  amount  of  pressure  required  to  change 
all  of  them,  and  consequently  the  strain,  is  lessened,  and  the  danger 
of  drawing  forward  the  teeth  used  for  anchorage  is  diminished.  It 
will  be  understood  that  after  teeth  have  begun  to  move  less  force  is 
required  to  continue  their  movement. 

A  convenient  appliance  for  moving  the  incisors  or  the  incisors  and 

cuspids  inward  is  made  as  seen  in  Fig.  209.     A  heavy  lingual  base- 

wire,  about  No.  12  gauge,  is 
x*  iG.  ^uy. 

arranged  to  follow  the  inner 

curve  of  the  arch  at  the  gum 
line,  having  a  space  between 
it  and  the  incisors,  its  ends 
well  anchored  with  partial- 
clasps  and  spring-clasp  at- 
tachments. A  Avire,  about 
No.  18  gauge,  is  formed  to 
the  labial  side  of  the  incisors,  crossing  them  usually  above  the  centre 
between  the  gum  and  incisive  edge.  Two  U-sliaped  loops  are  formed 
in  the  wire,  pointing  downward  and  resting  in  front  of  the  cuspids. 
The  ends  of  the  wire  extend  backward  on  a  line  with  the  part  of 
the  spring  that  crosses  the  incisors,  and  are  again  curved  to  pass 
over  the  arch  at  the  junction  of  two  of  the  teeth  at  either  side. 
The  ends  are  attached  with  solder  to  the  base-wire. 

Wli(;n  the  teeth  are  crowdfil,  i'c(|iiiring  tlu!  removal  of  a  bicuspid 
on  eith(,'rside  togetsjjace  for  their  movement,  the  loojjs  of  th(.' spring 
should   usually  be  arranged  opposite  the  spaces,  especially  when  it 


LOWER   INCISORS,  TO   MOVE    INWARD  217 

is  tho  intention  lo  move  all  of  the  six  front  teeth  inward  at  one 
time ;  the  part  of  the  spring  that  crosses  the  incisors  extending  also 
across  tlie  labial  side  of  the  cusj)ids.  With  the  latter  arrangement 
force  is  caused  for  their  movement  by  closing  the  loops  of  the  spring* 
as  required,  but  if  only  the  incisors  are  to  be  moved  in  the  manner 
illustrated  force  is  applied  by  bending  slightly  inward  with  flat-nosed 
pliers  the  mesial  side  of  each  of  the  loops  in  front  of  the  cuspids. 
The  twisting  of  the  wire  in  the  loops  gives  the  desired  force  for  the 
movement.  This  arrangement  of  the  spring  is  also  suitable  for 
moving  one  or  two  teeth. 

Fig.  210  represents  the  case  of  Mr.  S.,  aged   thirty-eight  years. 
The  four  lower  incisors  closed  in  front  of  the  upper  ones,  causing  a 

Fig.  210. 


poor  occlusion,  the  teeth  being  considerably  worn.  The  conditions 
in  this  case  were  corrected  by  making  the  changes  in  the  spring 
about  once  in  two  weeks,  the  patient  being  directed  to  remove  the 
appliance  regularly  for  cleansing.  The  regulating  and  retaining  was 
accomplished  in  fifteen  visits.  The  same  form  of  appliance  was 
used  for  correcting  a  similar  irregularity  for  a  daughter  of  Mr.  S.,  aged 
sixteen  years. 

When  the  incisor  and  cuspid  teeth  lap  considerably  in  front  of  the 
upper  ones,  their  movement  is  facilitated  by  opening  the  bite  (Fig. 
188).  But  sometimes  it  is  not  necessary,  and  no  provision  is  made 
for  opening  the  bite  to  assist  the  movement  of  the  incisors  from  the 
labial  to  the  lingual  side.  With  this  form  of  device  the  loop  can  fre- 
quently be  used  to  advantage  for  forcing  backward  a  cuspid  or  other 
tooth,  in  either  the  upper  or  lower  arch,  by  bending  the  end  of  the 
loop  inward. 

Fig.  211  shows  a  convenient  method  for  moving  inward  all  of  the 
incisors,  or  any  of  the  teeth  in  the  lower  arch.  In  this  case  it  was 
utilized  to  move  inward  the  first  left  lower  bicuspid,  cuspid,  and  lateral 
incisor,  and  the  right  cuspid.     All  of  these  were  closing  outside  of  the 


218  INCISOES 


upper  arch,  there  being  sufficient  space  to  permit  their  movement. 
A  Hngual  base-wire.  No.  12  gauge,  was  formed  and  anchored  in 
the  usual  manner.  A  spring  for  moving  the  teeth  on  the  left  side 
was  shaped   similar  in   form  to  a  continuous  spring-clasp,  extend- 


FiG.  211. 


ing  from  the  base- wire  over  the  arch  at  the  junction  of  the  teeth  to 
the  labial  side,  crossing  them  at  the  gum-line,  and  the  ends  attached 
with  solder  to  the  base-wire.  The  cuspid  on  the  right  side  was 
moved  into  line  with  a  spring  bent  twice  at  right  angles  and  attached 
to  the  base-wire  in  position  so  that  the  free  ends  would  extend  over 
the  arch  on  either  side  of  the  cuspid,  where  they  were  bent  towards 
one  another  to  rest  on  the  labial  side  near  the  gum.  The  action  of 
the  appliance  was  controlled  by  bending  the  labial  part  of  the  springs 
nearer  to  the  base-wire  from  time  to  time,  as  required. 

Figs.  121  and  123  illustrate  the  occlusion  of  the  teeth  before  and 
after  the  operation. 

Vulcanite  rubber,  in  place  of  the  base-wire,  properly  anchored 
with  wire-clasps  or  spring-clasps,  can  be  utilized  for  supporting  the 
springs  of  the  apparatus,  but  it  is  bulky,  and  not  as  strong  as  the 
appliances  I  have  described. 

Devices  for  moving  outward  the  lower  incisors  (Figs.  128,  129, 
130)  are  sometimes  applicable  for  moving  incisors  inward.  An  in- 
clined plane,  arranged  on  the  upper  teeth,  has  been  used  for  reducing 
proiiiincnco  of  the  lower  incisors  where  there  were  interdental  spaces 
between  llicni. 

Fig.  212.  When  additional  or  snj)plemcnfal  force  is  required  to 
move  backward   the  lower  incisors  and  cuspids  or  otiier  teeth,  and 


Fig.  212. 


LOWER  INCISORS,  TO  MOVE  INWARD 


219 


for  preventing  anchorage  teeth  from  moving  forward,  a  cross-bar,  or 
an  apparatus  as  illustrated,  may  be  worn  continuously  or  at  night. 
It  consists  of  a  chin-cap  and  wire-standards,  sup})orted  by  a  cranial- 
caj).  The  attachment  is  made  by  a  suspender  and  elastic  from  the 
caj)  to  each  standard,  passing  back  of  the  ears  ;  the  standard  passing 
through  a  short  tube  on  tlie  cap,  connected  with  an  elastic  extending 
from  a  hook  to  pass  over  an  adjustable  knob  on  the  standard  in 
front  of  the  ears.  To  the  teeth  to  be  moved  is  adjusted  an  infra- 
labial  bar  (Fig.  213).     It  is  usually  made  by  fitting  across  the  labial 

Fig.  213. 


faces  of  the  teeth  a  narrow  strip  of  thin  plate-metal,  and  shaping  a 
wire.  No.  18  B.  &  S.  gauge,  to  rest  on  the  plate-metal  near  tlie  low^er 
edge,  with  the  ends  curved  backward  to  pass  over  the  arcli  at  the 
junction  of  the  teetli  to  rest  on  the  lingual  side  of  some  of  those  to 
be  moved.  Another  wire.  No.  14  gauge,  is  shaped  to  rest  on  the 
plate-metal,  close  to  the  smaller  wire.  The  ends  are  curved  forward 
to  pass  over  the  low^er  lip,  near  the  corners  of  the  mouth,  and  again 
bent  backward  over  the  cheeks,  forming  arms.  Both  wires  are  tlien 
soldered  to  the  plate-metal,  and  a  small  knob  is  attached  near  the 
end  of  each  of  the  arms.  In  use,  elastic  bands  of  moderate  tension 
are  hooked  over  the  knobs  of  tlie  arms  and  knobs  on  the  standards. 
The  latter  are  provided  witli  screws,  and  are  adjustable  for  moving 
up  and  down  on  the  standard  to  get  a  correct  line  of  traction. 
When  desirable  the  infralabial  bar  can  be  made  as  illustrated  in  Fig. 
214,     Narrow  strips  of  plate-metal  are  bent  to  pass  over  and  rest  on 

Fig.  214. 


the  labial  and  lingual  sides  of  the  teeth  to  be  moved  and  attached  to 
the  bar  as  described.  The  lateral,  or  up-and-down  movement  of  the 
jaw,  does  not  interfere  materially  wdth  the  action  of  the  apparatus. 
Bars  of  this  character  can  be  utilized  in  correcting  the  position  of 
prominent  teeth  in  the  upper  arch. 


220  INCISORS 

Upper  Incisors,  to  move  Inward. — The  teeth  of  the  upper  arch 
are  more  important  to  the  expression  of  the  features  than  those  of 
the  lower  arch.  Great  care  should  be  exercised  for  their  preservation 
and  correction. 

In  the  normal  occlusion  of  the  teeth  the  upper  incisors  lap  some 
in  front  of  the  lower  incisors  and,  when  the  lips  are  closed,  the 
incisive  edge  of  the  upper  incisors  rests  a  little  below  the  inner  edge 
of  the  lower  lip.  The  lower  incisors  are  generally  erupted  first  and 
guide  the  upper  ones  to  position.  As  the  permanent  upper  incisors 
descend  they  excite  absorption  of  the  roots  of  the  deciduous  incisors. 
The  latter  occasionally  deflect  them  outward,  and  when  fully  erupted 
they  assume  a  position  considerably  in  advance  of  the  lower  ones, 
with  spaces  between  them,  sometimes  resting  on  the  outer  edge  of 
the  lower  lip.  If  allowed  to  remain  in  this  position,  the  pressure 
caused  on  them  by  the  lip  will  encourage  them  to  become  still  more 
prominent.  This  undue  protrusion  should  be  corrected  during  or 
soon  after  the  eruption  of  the  teeth,  unless  moving  them  should  prove 
detrimental  by  causing  too  much  lateral  pressure  on  other  teeth  that 
are  erupting.  Lateral  pressure,  when  too  severe,  will  in  some  cases 
arrest  the  eruption  of  the  adjoining  teeth,  and  especially  is  this  the 
case  with  the  lateral  incisors. 

When  incisors  outside  of  the  correct  circle  of  the  arch  are  to  be 
regulated  the  appliance  should,  if  practicable,  be  adjusted  inside  of 
the  arch.  It  is  less  conspicuous  and  more  agreeable  to  the  patient, 
but  the  occlusion  of  the  teeth  may  be  such  as  to  require  the  appliance 
to  be  arranged  on  the  labial  side. 

For  correcting  the  position  of  prominent  incisors,  when  it  is  desired 
to  lessen  the  prominence  of  the  process  as  well  as  of  the  teeth,  it  is 
well  to  keep  in  mind  that  the  force  should  be  applied  near  the  gum 
line. 

Fortunately  but  a  small  percentage  of  cases  require  the  movement 
bodily  of  the  teeth  with  the  process.  When  the  crowns  of  the  teeth 
need  to  be  tipped  inward  to  improve  the  angle,  the  force  should  be 
apj^lied  nearer  the  edge. 

When  one  of  the  incisors  is  too  promiin'iit,  Ijiil  has  a  surficient 
space  for  it  in  the  arch,  as  is  often  the  case  with  young  patients,  and 
occasionally  with  the  adult,  the  following  procedure  will  usually 
prove  effective. 

The  right  upper  incisor  being  the  tooth  to  be  moved,  a  spring-clasp 


UPPER  INCISORS,  TO  MOVE   INWARD 


221 


Fig.  215. 


.  >§' 


attachment  for  anchorage  is  formed  to  the  second  deciduous  molar, 
bicuspid,  or  one  of  the  i)eriiianent  molars  on  the  same  side  of  the  arch 
(Fig.  215),  and  a  small  spring-wire  soldered  in  the  anchorage  portion 
on  the  lingual  side,  extending  forward,  following  the  contour  of  the 
palatine  arch  as  nearly  as 
practicable,  and  formed  into 
a  U-shaped  loop  opposite  the 
cuspid,  its  end  terminating 
in  a  slight  hook  made  to  fit 
into  an  eyelet  on  the  lin- 
gual side  of  a  collar  in  suit- 
able position  that  has  been 
cemented  to  the  tooth  to  be 
moved. 

If  the  occlusion  with  the 
lower  teeth  is  so  close  as  to 
interfere  witli  the  collar  or 

eyelet,  the  use  of  tlie  collar  can  in  some  cases  be  dispensed  with 
by  making  the  end  of  the  spring  into  the  form  of  a  loop  similar  to  a 
spring-clasp,  the  end  of  the  loop  crossing  the  labial  side  of  the  in- 
cisor near  the  gum,  with  the  sides  extending  over  the  arch  at  the 
junction  of  the  incisor  with  the  adjoining  teeth,  to  the  gum  line,  but 
in  such  a  manner  as  not  to  interfere  with  the  articulation.  For 
young  patients,  when  the  conditions  will  permit,  it  is  advisable  to 
use  a  collar  cemented  to  the  tooth,  there  being  less  liability  of 
the  fixture  becoming  displaced.  In  favorable  cases,  in  place  of  the 
collar,  a  wire  with  a  small  eyelet  formed  in  the  side  for  the  hook 
of  the  spring  can  be  passed  around  the  tooth  and  the  ends  twisted 
togetlier  to  hold  it  firm.  Force  for  moving  the  incisor  is  ap})lied 
by  closing  the  loop  in  the  spring  slightly  from  time  to  time.  If  a 
single  spring-clasp  attachment  to  a  molar  is  not  sufficient  for  retaining 
the  device,  a  palatine  base-wire  can  be  utilized,  having  it  anchored 
with  spring-clasp  attachments  on  one  or  more  teeth  on  each  side  of 
the  arch. 

When  one  of  the  incisors  is  too  prominent,  with  insufficient  space 
to  admit  it,  with  its  companions,  to  the  proper  line,  an  appliance  for 
its  correction  can  be  made  as  follows : 

A  lingual  base-wire  is  formed,  extending  backward  on  either  side, 
following  the  gum  line  and  soldered  to  a  spring-clasp  attachment 


222 


INCISORS 


passing  over  a  molar  or  bicuspid  for  anchorage  (Fig.  216).  A  small 
spring-wire  should  then  be  bent  twice  at  right  angles,  the  distance 
between  the  parallel  arms  being  equal  to  the  width  of  the  tooth  to  be 
moved.     The  wire  is  formed  on  the  model  so  that  the  parallel  arms 

shall  extend  forward  from  the 
base-wire  somewhat  into  the 
space  between  the  adjoining 
teeth  back  of  the  incisor  to 
be  moved,  one  end  passing 
either  side,  to  broaden  the 
space  for  the  incisor  wdthout 
interfering  with  the  articula- 
tion. The  ends  are  then 
bent  upward  and  forward  to 
pass  over  the  arch  near  the 
incisive  edge  at  the  junction 
of  the  incisor  with  the  adjoining  teeth.  From  this  position  the  ends 
of  the  spring-wire  are  bent  to  the  gum  line,  then  towards  each  other 
to  pass  across  the  labial  surface  of  the  tooth  for  causing  pressure. 
The  spring  is  then  soldered  to  the  base-wire. 

In  some  cases  a  spring-wire  can  be  formed  like  the  one  used  for 
a  spring-clasp  attachment,  with  the  curved  portion  of  the  spring  cross- 
ing tlie   labial    side    of  p      9^7 
the    tooth,     the     ends 
extending   up    to    the 
edge  and  again  to  the 
base-wire,  where  they 
should     be     soldered. 
Fig.     152     shows    this 
form  of  spring  attached 
to  a  labio-buccal  base- 
wire. 

Fig.  217  illustrates  a 
device  with  but  one 
spring.  It  lias  been 
used  successfully  IV)r 
correcting  i)roiiiiiicnt 
teeth,  moving  Ihcni  inward  and,  when  recjuired,  rotating  them  at  the 
saiiM'  time. 


UPPP^R   INCISORS,    TO   MOVE   INWARD 


223 


Fig.  218. 


In  the  case  illustrated,  the  position  of  the  right  iipjjer  incisor  was 
to  be  corrected.  To  a  Hngual  base-wire,  well  anchored  to  the  bicus- 
pids and  molars,  was  attached,  opposite  the  tooth  to  be  moved,  one 
end  of  a  spring- wire, 
the  spring  being  shaped 
to  extend  over  the  arch 
near  the  incisive  edge, 
where  it  was  bent  at  a 
right  angle  to  rest  on 
the  labial  face  of  the 
incisor  near  the  gum. 
When  but  one  spring  is 
to  extend  over  the  arch 
in  this  manner,  if  de- 
sired, a  short  one  may 
be  formed  to  extend 
from  the  base-wire  to 
assist  in  broadening 
the  space  or  for  the  rotation  of  tlie  tooth.  Force  was  applied  by 
bending  the  front  part  of  the  spring  nearer  to  the  base-wire. 

Fig.  218  shows  a  similar  device  for  moving  left  incisors  inward 
and  laterally,  and  at  the  same  time  moving  a  cuspid  backward  to 

provide  space. 

In  Fig.  219  is  seen 
an  appliance  for  mov- 
ing inward  two  promi- 
nent upper  lateral  in- 
cisors and  cuspids.  A 
lingual  base-wire  is  an- 
chored with  spring- 
clasp  attachments  over 
the  second  bicuspids 
and  second  molars, 
with  partial-clasps  on 
the  adjoining  teeth.  A 
spring  is  attached  with 
solder  to  the  base-wire 
back  of  the  central  incisors ;  the  ends  are  curved  to  extend  over  the 
arch  at  their  junction  with  the  lateral  incisors,  crossing  them  near  the 


Fig.  219. 


224 


INCISORS 


gum,  for  moving-  them  inward.  Finger-springs  are  soldered  to  the 
partial-clasps  with  the  base-wire,  one  on  either  side  of  the  arch, 
extending  to  the  buccal  side  close  in  front  of  the  bicuspids,  and  are 
curved  to  rest  on  the  niesio-labial  surfaee  of  the  cuspids  for  moving 
them  backward  and  inward.  A  continuous  spring-clasp  can  be  used 
in  place  of  the  finger-springs  described  for  moving  a  lateral  and 
cuspid  inward,  by  arranging  it  to  pass  from  the  base-wire  to  the 
buccal  side  of  the  teeth  as  shown  on  the  right  side. 

In  the  arch  illustrated  in  Fig.  220  the  left  upper  incisor  had  ro- 
tated, lapping  considerably  in  front  of  the  incisor  on  the  right  side. 
]7j(3  220.  ^^  ^^'^s  found  by  measure- 

ment that  the  incisor  could 
not  be  moved  into  the 
circle  without  expanding 
the  arch  detrimentally  to 
the  occlusion  with  the 
lower  teeth.  Accord- 
ingly, the  first  left  upper 
bicuspid  was  extracted, 
and  an  appliance  made 
for  moving  the  incisors 
and  cuspid  backvv^ard.  A 
lingual  base-wire  was  ar- 
ranged to  rest  against  the  incisors  and  cuspid  not  to  be  moved  ;  its 
ends  were  well  anchored.  A  finger-spring  was  extended  from  the 
base-wire  and  partial-clasp  through  the  space  caused  by  the  extrac- 
tion, next  to  the  second  bicuspid  near  the  gum  line,  with  the  end 
reaching  in  a  curve  to  the  mesio-labial  side  of  the  irregular  incisor. 
Force  Avas  applied  by  curving  the  end  of  the  finger-spring  and  bend- 
ing it  nearer  the  base-wire,  which  moved  the  central  incisor  inward, 
at  the  same  tune  rotating  it,  and  forcing  the  others  backward  until 
the  cuspid  occupied  the  space  caused  by  the  extraction. 

The  teeth  were  retained  Avith  the  appliance  until  they  had  become 
firm  in  the  process,  when  a  gold  collar  was  cemented  to  the  central 
incisor,  with  a  spur  exiending  from  it  to  rest  on  IIk-  lingual  surface 
of  the  adjoining  incisor. 

A  secfjiidary  s})ring  can  be  added  when  necessary  for  causing  addi- 
tional force  for  rotating  or  evening  the  teeth. 

When  the  lowr-r  incisors  inipin;jc  on  the  gum  back  of  the  u})per 


UPPER  INCISORS,   TO  MOVE   INWARD 


225 


incisors,  interfering  with  the  application  of  the  lingual  base-wire, 
it  can  be  set  back  a  little  and  a  thin  piece  of  metal  sliaped  to  rest  in 
contact  with  the  lingual  side  of  tlie  teeth  and  soldered  to  it  (Fig.  221). 

Fiu.  221. 


Fig.  222  shows  an  appliance  that  was  utilized  to  correct  the  posi- 
tion of  two  upper  central  incisors  that  were  too  prominent  and  rotated 

Fig.  222. 


mesio-lingually.  The  first  bicuspids  had  been  removed  some  years 
previously  to  reduce  the  prominence.  The  appliance  was  made  by 
arranging  a  lingual  base-w-ire  to  pass  some  distance  back  of  the 
incisors,  with  the  ends  anchored  to  a  molar  on  each  side.  Two  small 
spring-wires,  bent  into  U-shaped  loops  pointing  towards  the  median 
line  were  soldered  to  the  base-wire,  one  on  either  side.  The  free 
ends  of  the  springs  hooked  into  eyelets  that  were  soldered  near  the 
gum  on  the  disto-lingual  side  of  collars  that  had  been  cemented  to 
the  incisors. 

15 


226 


INCISORS 


The  action  of  the  spring-wires  was  increased  by  removing  the 
apparatus  and  closing  the  loops,  which  rotated  and  drew  the  incisors 
nearer  to  the  base-wire.  After  the  central  incisors  were  moved  in- 
ward they  were  retained  by  passing  through  the  eyelets  a  wire  that 
was  slightly  curved  and  of  proper  length,  its  ends  resting  on  the 
lingual  side  of  the  lateral  incisors. 

One  or  more  prominent  incisors  can  readily  be  moved  into  position 
with  an  appliance  made  as  illustrated  in  Fig.  223.     A  lingual  base- 
jTic  223.  ^"^'ii's  is  extended  considerably 

back  of  the  teeth  to  be  moved, 
formed  into  a  desirable  curve 
and    anchored    with    partial- 
clasps  and  spring-clasp  attach- 
ments.   Spring-wires  are  then 
attached  to  the  base-wire,  one 
on  either  side,  in  form  to  ex- 
tend over  the  arch  at  the  junc- 
tion of  the  central  and  lateral 
incisor  to  the  gum  line,  where 
they  are  bent  at  an  angle  to 
cross  the  labial  faces  of  the  teeth  to  be  moved.     The  necessary  strain 
is  caused  by  bending  the  end  of  the  springs  nearer  to  the  base-wire. 
If  the  teeth  move  easily,  and  there  is  sufficient  space,  usually  one 
spring  will  cause  enough  force  for  the  movement  of  two  teeth.     It  is 


Fig.  224. 


r^m^":"'^^ 


advisable  to  make  only  slight 
changes  at  a  time  in  the 
shape  of  the  springs,  and  not 
oftener  than  once  in  from 
three  to  seven  days. 

An  efficient  device  that 
is  equally  applicable  for  the 
movement  inward  or  the  ro- 
tation of  one  or  more  of  the 
incisors  is  shown  in  Fig.  224. 
It  is  made  with  a  lingual 
base-wire  following  the  curve 
of  the  arch  far  enough  back  of  the  teeth  to  permit  them  to  be  moved ; 
its  ends  are  fixed  with  partial-clasps  and  spring-clasp  attachments  to 
the  molars  and  adjoining  teeth. 


UPPER  INCISORS,   TO  MOVE   INWARD 


227 


A  spring-wire,  about  No.  19  gauge,  is  shaped  to  cross  the  labial 
faces  of  the  incisors  to  be  moved  rather  near  their  incisive  edge  (Fig. 
225).  An  oblong  loop  is  formed  in  the  wire  on  either  side  extending 
towards  the  gum  ;  the  free  ends  of  the  loop  are  shaped  to  pass  over 


Fio.  22o. 


the  arch  at  the  junction  of  the  central  and  lateral  incisors  to  be  sol- 
dered to  the  base-wire. 

The  action  of  the  spring  is  induced  by  bending  backward  the  part 
that  crosses  the  labial  side  of  tlie  incisors  a  little  from  time  to  time 
with  flat-nosed  pliers,  causing  it  to  rest  nearer  the  base-wire.  The 
arms  of  the  spring  that  pass  over  the  arch  should  not  be  permitted 
to  press  hard  against  the  lateral  incisors  excepting  where  it  is  desired 
to  move  them  laterally  outward  for  increasing  the  space.  If  the 
lingual  base-Avire  interferes  with  the  tongue  in  pronunciation,  and 
rotation  of  the  teeth  is  not  required,  the  space  back  of  the  incisors 
can  be  left  free  by  using  a  palatine  base-wire. 

In  Fig.  226  is  seen  a  device  made  similar  to  those  previously 
described  that  was  utilized  for  moving  inward  and  rotating  two  upper 

Fig.  226. 


central  incisors  for  Miss  M.,  aged  sixteen  years,  and  also  used  as 
a  retainer.  The  patient  had  a  fall  when  about  nine  years  of  age, 
fracturing  the  edges  of  each  of  the  central  incisors,  and  causing  the 
death  of  their  pulps.  The  teeth  had  assumed  a  prominent  position, 
and  were  twisted  outward. 

The  device  was  constructed  with  a  lingual  base-wire,  anchored 
with  partial-clasps  and  spring-clasp  attachments.     The  spring  of  the 


228 


INCISORS 


appliance  was  formed  into  three  U-shaped  loops,  crossing  the  labial 
faces  of  the  incisors  to  be  moved,  the  two  outer  loops  pointing  towards 
the  gum.  The  ends  of  the  spring  passed  over  to  the  lingual  side  of 
the  arch  at  the  junction  of  the  central  and  lateral  incisors  on  either 
side,  to  be  attached  to  the  base-wire.  The  centre  loop  extended 
downward  to  cause  pressure  on  the  mesial  and  labial  surface  of  each 
of  the  incisors  near  their  edge.  Additional  force  was  applied  by 
bending  the  loops  of  the  appliance  backward  towards  the  base-wire, 
adjusting  them  so  that  the  centre  loop  would  cause  stress  for  ro- 
tating. 

Care  should  be  exercised  so  to  shape  the  wires  that  they  will 
not  cause  pressure  upward  where  they  pass  over  at  the  junction 
of  the  teeth,  as  slight  pressure  at  this  point  is  liable  to  separate 
them. 

When  both  of  the  upper  central  incisors  are  too  prominent,  as  a 
result  of  pyorrhoea  or  other  cause,  an  appliance  can  be  made  for  their 
correction  by  first  cementing  to  each  of  them  a  platina-gold  collar, 
provided  with  an  eyelet  on  the  lingual  side  made  of  wire,  parallel 
with  and  near  the  gum  (Fig.  227).     When  desirable  the  eyelets  can 

Fig.  227. 


be  cemented  into  pits  in  the  teeth.  A  palatine  base-wire  is  anchored 
with  spring-clasp  attachments  to  the  molars  and  partial-clasps  on  the 
adjoining  teeth.  A  semicircular  spring  of  suitable  size  is  arranged 
to  rest  in  contact  with  the  irregular  incisors,  following  the  contour 
of  the  teeth  at  the  gum  line,  and  bent  into  a  loop  on  either  side,  the 
ends  extending  backward  to  be  fastened  in  the  anchorage.     A  small 


UPPER  INCISORS,   TO  MOVE  INWARD  229 

wire  hook  is  formed  to  pass  into  each  of  the  eyelets  and  soldered  to 
the  spring  near  the  median  line.  By  closing  tiie  loops  a  little 
and  readjusting  the  appliance,  force  is  exerted  to  draw  the  incisors 
inward. 

For  the  correction  of  the  position  of  prominent  incisors  with  spaces 
between  them,  a  device  made  similar  to  that  seen  in  Fig.   228  is 

Fig.  228. 


generally  convenient  and  effective.  The  anchorage  consists  of  a 
spring-clasp  attachment  over  a  molar  on  either  side.  In  addition, 
partial-clasps  are  fitted  to  the  adjoining  teeth,  with  a  wire-clasp  ex- 
tending to  the  distal  surface  of  the  last  molar  and  the  anchorage 
portions  connected  with  a  palatine  base-wire.  A  spring-wire  is 
bent  into  a  curve  or  semicircle  to  rest  near  the  lingual  surface  of 
the  incisors,  extending  backward  on  either  side  and  formed  into  a 
U-shaped  loop,  the  loops  being  located  just  anterior  to  the  anchor- 
age portion,  pointing  towards  the  median  line.  The  ends  of  the 
spring  are  soldered  to  the  partial-clasps  with  the  ends  of  the  base- 
wire. 

A  T-piece  is  made  from  plate-metal,  slightly  curved  backward  and 
shaped  like  a  bar  to  cross  the  fronts  of  the  incisors,  with  the  ends 
projecting  at  right  angles  and  bent  into  hooks  to  pass  over  the  edge 
of  the  teeth  to  prevent  the  bar  from  pressing  towards  the  gum 
when  force  is  applied.  To  complete  the  T,  another  piece  of  plate- 
metal  is  soldered  to  the  centre  of  the  bar  in  shape  to  pass  between 
the  incisors  and  united  to  the  spring.     The  action  of  the  appliance 


230 


INCISORS 


is  caused  by  closing  the  U-shaped  loops  in  the  spring,  making  only- 
slight  changes  at  a  time,  as  too  much  force  is  not  desirable. 

Fig.  229  illustrates  a  device  with  a  palatine  spring  base-wire,  and  a 
double  looped  spring  for  moving  inward  four  upper  incisors.  It  is 
anchored  in  the  usual  manner,  with  one  or  more  spring-clasp  attach- 
ments and  partial-clasps  on  each  side  of  the  arch.     The  spring  is 

Fig.  229. 


arranged  to  cross  the  labial  faces  of  the  teeth  to  be  moved  and  to  extend 
over  the  arch  near  the  incisive  edge  at  the  junction  of  the  lateral  in- 
cisors and  cuspids,  where  a  U-shaped  loop  is  formed  and  the  ends 
are  extended  to  be  attached  in  the  anchorage  with  the  ends  of  the 
base-wire.  Force  is  exerted  by  closing  the  loops.  When  required, 
the  spring  base-wire  is  utilized  for  expanding  the  arch  laterally. 

When  all  of  the  incisors  in  either  the  upper  or  lower  arch  are  too 
prominent,  with  spaces  between  them,  and  need  to  be  moved  inward 
to  proper  lino,  an  appliance  as  represented  in  Fig.  230  will  usually 
be  found  adequate.  A  lingual  base-wire  is  formed  to  follow  the 
curve  of  the  arch  a  little  back  of  the  circle  it  is  desired  the  incisors 
shall  assume  when  regulated ;  the  ends  extending  on  either  side 
and  anchored  by  partial-clasps  and  spring-clasp  attachments  to  the 
teeth  in  the  distal  part  of  the  arch.  A  small  spring-wire  is  soldered 
to  the  base-wire  at  the  junction  of  the  right  cuspid  and  lateral, 
extending  forward  to  the  distal  surface  of  the  lateral  near  the  incisive 


UPPER   INCISORS,    TO   MOVE   INWARD 


231 


edge,  being  formed  so  that  it  will  not  interfere  with  the  occlusion. 
The  spring-wire  is  next  bent  to  extend  near  the  gum  line  and  curved 
to  cross  the  labial  faces  of  the  incisors  to  the  distal  surface  of 
the  lateral  on  the  opposite  side,  where  it  is  bent  in  a  similar  form  to 
extend  over  the  arch  to  be  united  to  the  base-wire.  The  portion  of 
the  spring  passing  from  the  base-wire  to  the  labial  side  should  always 
extend  to  the  edge  of  the  incisors  and  thus  over  the  arch,  not  pass- 
ing between  the  teeth,  even  though  there  be  room  for  it,  as  this 
curve  necessarily  makes  the  spring  of  suitable  shape  to  act  on  the  in- 
cisors to  move  them  into  line.  When  force  is  required,  the  appliance 
is  removed  and  the  arm  of  the  spring  that  passes  from  the  base- 
wire  is  bent  more  acutely,  causing  the  labial  part  of  the  spring  to 
assume  a  position  closer  to  the  base-wire.     If  there  are  spaces  be- 


tween the  incisors  it  will  be  found  that  as  the  teeth  are  moved 
inward  the  part  of  the  spring  that  crosses  the  labial  side  will  be- 
come too  long  to  reach  from  the  distal  surface  of  one  lateral  to  that 
of  the  other,  on  account  of  their  moving  towards  the  median  line, 
closing  the  spaces.  This  condition  is  corrected  by  making  a  slight 
loop  in  the  wire  at  the  median  line,  which  shortens  it ;  or  a  ring  can 
be  made  at  the  gum  line  in  the  end  of  one  of  the  amis  that  pass 
over  the  arch,  through  which  the  end  of  the  wire  that  crosses  the 
labial  surface  can  pass. 

In  many  cases  presented  for  treatment  the  cuspids  need  to  be 
moved  outward,  and  tlie  incisors  are  too  prominent,  with  spaces 
between  them. 


232 


INCISORS 


Fig.  231  shows  an  appliance  used  for  the  correction  of  these  con- 
ditions for  Master  K.,  aged  thirteen  years. 

The  upper  incisors  projected  forward  and  closed  over  the  lower 
lip.     A  palatine  base-wire  was  formed  to  cross  the  arch,  the  ends 


Fig.  231. 


held  with  spring-clasp  attachments  over  the  second  bicuspids.  For 
moving  the  cuspids  outward  a  spring-wire,  No.  17  gauge,  ^vas  bent 
into  three  U-shaped  loops,  the  middle  loop  pointing  backward  at  the 
median  line.  The  outer  sides  of  the  other  loops  passed  under  a 
lug  attached  to  a  collar  cemented  to  each  of  the  cuspids.  The 
ends  of  the  spring  were  attached  to  the  partial-clasps  beside  the 
ends  of  the  base-wire.  The  incisors  were  moved  into  line  by  a 
semicircular  spring  shaped  to  the  labial  side  of  them,  having  a  large 
U-shaped  loop  formed  in  it  opposite  the  cuspid  on  either  side,  pro- 
jecting upward  under  the  lip.  The  free  ends  extended  backward  and 
were  attached  with  solder  to  the  spring-clasps.  These  attachments 
were  made  strong  by  passing  a  thin  piece  of  plate-metal  under  the 
spring-clasp  and  spring  before  soldering.  The  spring  was  prevented 
from  slipping  upward  on  tlie  teeth  by  soldering  to  it  at  the  median 
line  a  thin  piece  of  metal  about  one-eighth  of  an  inch  wide,  bent 
into  the  form  of  a  hook,  to  hook  over  the  edge  of  the  central  in- 
cisors. Both  springs  were  made  to  act  at  the  same  time,  opening 
the  loops  gradually  for  moving  outward  the  cuspids,  and  closing 
the  loops  in  the  semicircular  spring  slightly,  to  apply  force  to  the 
labial  side  of  the  incisors  for  moving  them  inward.     After  the  teeth 


UPPER   INCISORS,   TO   ^lOVE  INWARD  233 

were  in  position  tlie  same  appliance  was  worn  several  months  for 
retaining  tliem. 

When  a  regulating  appliance  is  continued  in  use  for  retaining,  the 
springs  should  not  be  allowed  to  rest  heavily,  as  the  slightest  press- 
ure would  cause  movement  and  final  <rim[)ing  of  the  teeth. 

Fig.  232  represents  an  appliance  used  in  the  case  of  Master  C, 
aged  thirteen  years,  for  moving  prominent  front  teeth  inward,  and  later 

Fig.  232. 


expanding  laterally  the  anterior  part  of  the  arch  for  their  continued 
movement.  A  strong  anchorage  was  made  by  forming  spring-clasp 
attachments  to  the  second  deciduous  molars  and  partial-clasps  on  the 
adjoining  teeth,  the  sides  connected  with  a  palatine  base-wire.  The 
base-wire  crossed  rather  far  back  where  the  arch  was  sufficiently 
broad.  A  semicircular  spring  with  two  U-shaped  loops  was  formed  to 
the  labial  faces  of  the  incisors  and  cuspids,  the  loops  being  shaped  some- 
what to  the  contour  of  the  gum  under  the  lip ;  the  distal  part  passed 
over  the  arch  at  the  junction  of  the  cuspids  with  the  first  bicuspids, 
and  was  joined  to  the  partial-clasps  in  the  anchorage.  The  arch  was 
expanded  laterally  by  bending  outward  slightly  at  intervals  the  front 
part  of  the  anchorage  portions  and  at  the  same  time  closing  the  loops 
in  the  spring  for  moving  the  incisors  inward. 

An  appliance  used  for  regulating  a  V-shaped  arch,  expanding  it 
at  the  position  of  the  bicuspids  and  flattening  the  anterior  part  by 
moving  the  incisors  inward,*  and  which  has  been  used  for  expand- 

*  Jackson,  Dental  Cosmos,  1891,  p.  1077. 


234 


mcisoRS 


Fig.  233. 


ing  the  Avhole  arch  laterally  or  for  moving  outward  individual  teeth, 
is  illustrated  in  Fig.  233.  It  is  made  by  arranging  a  lingual  spring 
base-wire  to  follow  the  inner  curve  of  the  arch  at  the  gum  line,  the 

ends  being  united  by  a 
spring  -  clasp  attachment 
for  anchorage  to  one  or 
more  teeth  on  each  side. 
From  each  anchorage  a 
small  wire  is  shaped  to 
extend  over  the  arch  at 
the  junction  of  the  teeth 
at  any  desirable  location, 
\vith  the  end  bent  into  the 
\^  form  of  a  hook  or  eyelet. 
\  A  straight  spring- wire  is 
arranged  to  cross  the  labial 
side  of  the  incisors  ;  its  ends  are  sprung  back  to  the  buccal  side  of  the 
bicuspids,  and  held  in  that  position  by  the  eyelets  or  hooks.  The  arch 
is  expanded  laterally  by  bending  outward  the  ends  of  the  base-wire, 
and  the  tendency  to  straighten  of  the  wire  that  is  sprung  around  the 
front  of  the  arch  applies  force  to  the  labial  side  of  the  incisors  to 
move  them  inward,  and 
at  the  same  time  assists 
the  action  of  the  base- 
wire.  If  the  spring  is 
not  well  retained  on  the 
fronts  of  the  incisors,  a 
piece  of  partial-clasp  metal 
or  wire  should  be  shaped 
to  extend  into  the  de- 
pressions underneath  it 
and  over  the  edge,  causing 
pressure  on  the  points  de- 
sired, and  attached  to  the 
spring  w'ith  solder. 

An  aj)paratus  that  has  been  used  for  moving  the  six  front  teeth 
inward  at  one  time,  closing  the  spaces  caused  by  the  extraction  of 
the  first  bicuspids,  is  depicted  in  Fig.  234.  A  palatine  base-wire  is 
formed   to   cross   the  arch.      The  ends  are  anchored  with  partial- 


FiG.  234. 


UPPER  INCISORS,   TO  MOVE  INWARD  235 

clasps  and  spring-clasp  attachments,  and  a  wire-clasp  on  each  side 
extends  backward  from  the  pariial-clasps  to  the  distal  side  of  the 
second  molars,  the  latter  being  ai)piied  to  advantage  for  strengthen- 
ing the  anchorage  when  teeth  are  only  partially  erupted. 

For  moving  the  incisors  and  cuspids  inward  a  small-sized  spring 
is  formed  into  a  semicircle  to  cross  the  labial  surface  near  the  gum, 
then  shaped  to  pass  through  the  spaces  back  of  the  cuspids,  but  not 
fitting  close  to  them,  and  formed  into  a  large  U-shaped  loop  on 
either  side,  pointing  towards  the  median  line,  with  the  ends  bent 
backward  to  cross  the  partial-clasps  and  soldered  w'itli  the  ends  of 
the  base-wire. 

It  will  be  observed  in  this  case  that  there  are  two  molars  and  one 
bicuspid  on  each  side  utilized  for  anchorage,  which  in  most  cases  is 
sufficient,  but  it  is  not  uncommon  for  the  teeth  used  for  anchorage 
to  be  moved  forward  somewhat  when  force  is  applied  for  moving 
the  six  front  teeth  inward  at  one  time.  Usually,  therefore,  it  is  the 
wiser  plan  to  begin  the  operation  by  first  causing  pressure  on  the 
central  incisors,  straightening  slightly  the  semicircular  spring  at  the 
median  line.  The  pressure  on  the  incisors  alone  causes  them  to 
act  as  a  wedge  between  the  adjoining  ones,  and  less  strain  is  required 
to  actuate  all  of  them,  consequently  less  liability  to  move  forward 
the  teeth  used  for  anchorage. 

Two  finger  springs  extending  to  the  labial  side  of  the  teeth,  one 
from  either  side,  as  illustrated  in  Fig.  207,  is  sometimes  more  easily 
manipulated.  When  necessary,  to  prevent  the  disturbance  of  the 
anchorage  teeth,  additional  anchorage  can  be  gained  by  the  use  of  a 
palatine  plate,  or  by  supplemental  force  applied  with  a  cross-bar. 

In  Fig.  235  is  shown  a  profile  view  of  the  features  of  Master  P., 
aged  twelve  years,  taken  from  a  plaster  model.  The  patient  was  a 
mouth-breather,  for  the  relief  of  which  the  tonsils  and  adenoid 
growths  were  removed.  The  upper  incisors  were  very  prominent, 
closing  considerably  in  front  of  the  lower  lip  and  with  spaces  between 
them.  For  their  correction,  an  appliance  w^as  first  made  as  seen  in 
Fig.  236,  with  a  palatine  base-wire  crossing  the  arch.  Spring-clasps 
were  passed  over  the  first  molars,  and  partial  clasps  on  the  molars 
and  bicuspids,  with  wire-clasps  extending  backward  to  encircle  the 
second  molars  for  retaining.  A  spring- wire.  No.  19  gauge,  for  mov- 
ing the  incisors  inward  was  bent  into  a  semicircle  to  cross  the  labial 
side  of  them  near  the  gum,  with  a  large  U-shaped  loop  formed  in 


236 


INCISORS 


the  wire  opposite  the  cuspid  on  either  side.  This  extended  up 
under  the  Hp  and  reached  from  the  mesial  side  of  tlie  cuspid  to  the 
mesial  side  of  the  first  bicuspid,  where  the  end  passed  over  at  the 
junction  of  the  teeth  to  the  inner  side  of  the  arch  to  be  attached  to 

the  partial  clasps.     This  part 

^^«-236.  ../^         .        /ill  1 

or  the  sprmg  should  always  be 

curved  sufficiently  downward 
to  permit  it  to  pass  over  the 
arch  without  causing  an  up- 
ward pressure  on  the  teeth, 
which  w^oulcl  act  as  a  wedge, 
and  would  eventually  sepa- 
rate them  if  they  were  close 
together ;  while  if  there  were 
spaces  between  the  teeth,  and 
the  spring  was  not  curved 
downward  enough,  it  would 
prevent  the  teeth  being  moved  entirely  together.  The  loops  were 
closed  to  give  the  required  force. 

Ill  this  case,  after  the  incisors  were  moved  inward,  closing  the 
spaces  betw-een  them,  a  careful  measurement  Avas  made  with  accurate 
models,  and  it  was  found  that  if  the  first  bicuspids  were  extracted, 
there  would  be  just  enough  space  to  permit  the  incisors  to  be  moved 
inward  sufficiently  to  give  a  proper  occlusion,  and  to  give  the  features 
a  good  contour.  Accordingly  the  first  bicuspids  were  extracted,  and 
the  same  form  of  appliance  was  utilized  for  continuing  the  movement 
of  the  incisors  and  cuspids  inward.  To  prevent  the  teeth  used  for 
anchorage  from  moving  forward  under  the  pressure  rec|uired,  supple- 
mental force  was  applied  by  the  adjustment  of  a  cross-bar  and  cranial- 
cap  as  seen  in  Fig.  237.  (For  details  of  making,  see  page  97.)  The 
teeth  and  process  were  gradually  forced  inward,  causing  a  good  occlu- 
sion and  permitting  the  lips  to  close  normally.  Fig.  238  shows  a 
model  of  the  improved  features  of  the  patient  taken  within  a  year 
from  the  commencement  of  the  regulation. 

Anterior  i)rotrusion  is  usually  the  result  of  excessive  development. 
(See  Etiology.)  Wlien  there  is  a  lack  of  harmony  in  the  prominence 
or  size  of  the  upper  and  lower  arches,  tliey  should  be  e(|ualized. 
(See  Chapter  XIX.,  Receding  Lower  Jaw.)  If  it  is  dclormined  that 
the  arch  can  be  enlarged  sufficiently  to  properly  admit  the  irregular 


Fic.  2.'?r). 


Fig.  238. 


Fig.  237. 


Fig.  2;». 


Fig.  240. 


UPPER   INCISORS,  TO    IMOVE  INWARD 


237 


teeth,  apparatus  should  be  employed  as  described  in  Chapter  IX., 
Expansion  of  the  Dental  Arch.  But  when  it  is  found  from  a  careful 
study  of  the  case  that  equalizing  the  arches  or  expansion  is  not  ad- 
visable, space  for  the  correction  should  be  gained  by  the  extraction 
of  one  or  more  teeth,  as  the  first  bicuspids.  All  of  the  space  caused 
by  the  extraction  is  frequently  required  to  reduce  the  unpleasant 
prominence.  Otherwise,  when  all  of  the  teeth  are  retained,  the  arch 
is  unduly  crowded,  the  contour  of  the  features  marred,  and  the  lips 
drawn,  interfering  with  speech  and  encouraging  mouth-breathing.  In 
this  chapter  a  number  of  cases  are  cited  in  which  extraction  was 
employed  to  good  advantage,  as  verified  by  the  results. 

Fig.  239,  Master  G.,  aged  nine  years,  shows  a  case  of  anterior  pro- 
trusion with  inability  to  close  the  lips.  There  were  spaces  between 
the  teeth.  The  incisors  and  cuspids  were  moved  inward  Avitli  a 
metal  device  made  similar  to  Fig.  236. 

In  Fig.  240  is  illustrated  an  apparatus  for  causing  supplemental 
force  that  is  superior  in  reducing  some  forms  of  anterior  protrusion. 
It  is  usually  worn  at  night.  A  chin-cap  with  wire  standards  sup- 
ported by  a  cranial-cap  is  made  as  described  on"  i)age  218.  To  the 
teeth  to  be  moved  is  adjusted  a  supralabial  bar  hinged  to  a  metal 
device  passing  over  the  teeth  (Fig.  241).    (See  description  of  making, 


Fig.  241. 


on  page  100.)  Force  is  given  by  small  rubber  bands  passing  over 
the  knobs  of  the  bar  and  knobs  of  the  wire  standards.  The  latter 
are  adjustable  for  changing  the  line  of  traction. 

An  appliance  made  by  attaching  springs  in  a  rubber  plate  for 
reducing  upper  anterior  })rotrusion  has  its  advantages.  I  have  sug- 
gested some  objections  to  the  anchoring  of  fixtures  with  a  rubber 
plate  by  extending  the  rubber  over  the  grinding  surface  of  the  molar 
and  bicuspid  teeth,  a  method  which  endangers  the  occlusion,  etc. 
But  there  is  no  doubt  that  a  rubber  plate  covering  the  roof  of  the 
mouth  assists  the  anchorage  for  moving  incisors  and  cuspids  inward 


238  INCISORS 

by  tlie  additional  resistance  it  offers  in  resting-  against  the  anterior 
palatine  arch  while  traction  is  being  caused.  The  plate  is  easily 
removed  by  the  patient  for  cleansing. 

Fig.  242  illustrates  a  vulcanite  plate  with  flnger-springs.     I  first 
described  this  appliance  in   1888,*  having  used  it  for  several  years. 

Fig.  242. 


The  plate  is  fitted  well  to  the  necks  of  the  teeth,  and  retained  by 
wire-clasps  extending  from  the  rubber  around  the  last  erupted  molar 
teeth  and  by  others  passing  through  spaces  and  around  the  second 
bicuspids.  When  the  anchorage  is  to  include  molars  that  are  not 
fully  erupted  the  model  back  of  the  molars  should  be  carved,  re- 
lieving some  of  the  gum  portion  for  the  accommodation  of  the  wire- 
clasps.  Sometimes  it  is  an  advantage  to  use  a  small  wdre  for  the 
clasp,  as  it  can  be  curved  to  fit  the  tooth  more  accurately,  and  when 
required  bent  upward  at  a  right  angle,  projecting  under  the  gimi  to 
the  neck  of  the  tooth.  When  this  anchorage  is  not  sufficient  a  care- 
fully fitted  i)arlial-clasp  can  be  soldered  to  project  under  the  gum, 
first  bending  the  wire  backward  a  little.  A  finger-spring,  about  No. 
18  gauge,  is  shaped  to  extend  from  the  plate  on  either  side  of  the 
arch,  i»assing  close  to  the  mesial  surface  of  the  second  bicuspid,  to 
the  buccal  side  ;  it  is  then  bent  to  follow  the  ginii  line  across  the  labial 
faces  of  the  incisors  and  cuspids,  and  left  long  in  order  to  reach 
somewhat  beyond  the  median  line  to  mutually  support  one  another. 


*  Jackson,  Dental  Co.smos,  1888,  ]>.  510. 


UPPER   INCISORS,    TO   MOVE   INWARD  239 

The  spring-wire  for  this  purpose  should  be  rather  stiff,  owing  to  its 
length,  but  not  too  stiff,  as  a  slight  pressure  will  accomplish  more 
than  would  naturally  be  supposed  by  those  who  have  not  used  spring 
pressure.  A  portion  of  the  wire  that  enters  the  plate  should  be 
flattened  to  add  strengtli  to  the  anchorage,  but  the  part  that  extends 
from  the  plate  should  always  be  round,  which  permits  of  changes 
of  form  by  bending  that  could  not  be  accomplished  by  the  use 
of  the  half-round,  square,  or  flat  wire.  The  anterior  edge  of  the 
plate  opposite  the  teeth  to  be  moved  should  be  dressed  away  from 
time  to  time  sufficiently  to  let  them  take  a  good  alignment,  and  very 
gradual  force  applied  with  the  springs.  When  the  teeth  are  to  be 
moved  inward  a  considerable  distance  with  this  form  of  appliance, 
the  plate  should  be  dressed  away  only  a  little  at  a  time,  otherwise 
some  of  the  teeth  would  be  likely  to  move  inward  before  others,  and 
to  take  a  crimped  or  rotated  position. 

The  gum  does  not  absorb  as  readily  as  alveolar  process,  and  ac- 
cordingly when  the  teeth  are  moved  rapidly  towards  the  plate  it 
causes  the  gum  to  bulge  ;  occasionally  it  becomes  congested  and 
protrudes  below  the  edge  of  the  plate.  ^ 

Either  the  regulation  should  proceed 
more  slowly  or  the  gum  be  snipped 
away  with  curved  scissors. 

Fig.  243  illustrates  the  position  of 
the  teeth  of  a  boy  aged  twelve  years. 
The  incisors  and  cuspids  in  the  upper 
arch  were  much  too  prominent  and  so  crowded  as  to  require  the  ex- 
traction of  the  first  bicuspids  to  permit  the  teeth  to  be  moved  to  articu- 
late with  those  of  the  lower  arch  (Fig.  244).  A  model  Avas  made 
and  trimmed  accurately  at  the  necks  of  the  molars  and  second  bicus- 
pids that  were  used  for  anchorage.  A  vulcanite  plate  with  finger- 
springs  was  employed.  Fig.  245  shows  the  position  of  the  springs 
of  the  appliance  and  the  occlusion  of  the  teeth  when  the  regulation 
was  nearly  completed.  The  same  apparatus  was  used  for  retaining, 
the  finger-springs  being  shaped  to  rest  very  lightly  against  the  teeth. 

It  is  seldom  necessary  to  make  any  attachment  to  the  ends  of  the 
springs  to  hold  them  in  a  given  position  on  the  labial  side  of  the 
incisors.  In  beginning  the  operation,  when  the  incisors  incline  con- 
siderably forward,  the  springs  are  sometimes  caused  to  slide  towards 
the  gum.     In  such  a  case  a  narrow  piece  of  plate-metal  bent  into 


240 


INCISOES 


an  S-shape,  with  one  end  passed  over  the  edge  of  the  incisors  and 
the  other  above  the  springs,  will  hold  them  in  proper  position.     Its 
use  is  generally  required  for  a  short  time  only,  but  the  metal  can  be 
soldered  to  one  of  the  springs  if  desired. 
Fig.  244. 


Fig.  245. 


If  the  spring  presses  too  hard  on  any  particular  tooth,  it  can  be 
remedied  by  changing  its  shape.  The  pressure  of  the  springs  should 
be  relieved  when  the  teeth  are  in  good  alignment,  as  at  this  stage  of 
the  regulation  it  requires  but  the  slightest  force  to  continue  move- 
ment.   If  force  is  continued  with  the  springs,  the  teeth  will  be  pressed 

Fig.  246. 


against  the  rubber  on  tht-ir  lingual  side,  and  being  somewhat  wedge- 
shaped,  they  Avould  be  depressed  in  their  alveoli,  shortening  them. 

These  suggestions  are  also  applicable  when  a  single  spring  is  used 
in  this  manner  or  when  a  semicircular  spring  with  U-shaped  loops 
similar  to  Fig.  246  is  employed.     The  latter  is  often  preferred  in 


UPPER   INCISORS,   TO   MOVE  INWAIU) 


241 


correcting  anterior  protrusion.  The  plate  is  anchored  with  wire- 
clasps.  To  the  sides  are  attached  the  ends  of  a  looped  semicir- 
cular spring.  The  spring  is  shaped  to  rest  on  the  labial  side  of  the 
teeth  to  be  moved,  the  loops  being  arranged  to  project  upward 
under  the  lip  opposite  the  cuspids  or  first  bicuspids.  Force  is 
exerted  by  closing  the  loops  slightly  at  a  time.  Usually  the  ends 
of  the  spring  are  attached  in  the  rubber,  but  when  desired  the  ends 
can  be  bent  into  hooks  and  hinged  either  to  the  plate,  to  a  base- 
wire,  to  spring-clasps,  or  to  wire-clasps. 

When  the  lateral  incisors  are  too  prominent  and  overlap  the 
central  incisors,  it  is  sometimes  necessary  to  make  space  for  their 
correction.      Fig.    247    shows    an    appliance    for    moving    inward 

Fig.  247. 


and  rotating  lateral  incisors.  In  the  case  illustrated  the  first  bicuspids 
were  extracted  and  the  cuspids  moved  backward  into  the  spaces  by 
the  force  applied  to  the  laterals.  A  palatine  plate  is  well  anchored  to 
the  distal  molars.  Spring-wires  are  arranged  in  the  anterior  part 
of  the  plate  to  extend  over  the  arch  at  the  edge  and  junction  of 
the  central  and  lateral  incisors  to  reach  near  the  gum,  where  each 
of  the  springs  is  bent  back  on  itself,  forming  a  loop  with  the  ends 
terminating  on  the  mcsio-labial  side  of  the  laterals.  Force  is  caused 
by  bending  the  loop  portion  of  the  springs  laterally  backward  from 
time  to  time.  An  appliance  with  springs  formed  in  this  manner  can 
be  used  for  retaining  the  incisors,  moving  them  laterally,  or  rotating 
them  by  bending  the  free  end  of  the  springs  as  required. 

The  following  illustrate  a  few  typical  cases  of  anterior  upper  pro- 
trusion before  and  after  correction. 

16 


242  INCISORS 

Fig.  248.  Miss  R.,  aged  fourteen  years.  Case  of  hereditary 
prominence  of  the  upper  arch  and  history  of  thumb-sucking.  The 
first  upper  bicuspids  were  extracted  and  a  palatine  plate  with  a 
semicircular  spring  was  inserted  for  reducing  the  prominence.  The 
lower  incisors  and  cuspids  needed  to  be  depressed  in  their  alveoli, 
and  a  plate  thickened  in  its  anterior  portion  similar  to  Fig.  338  was 
employed.  This  depressed  the  low^er  incisors,  and  at  the  same 
time  the  upper  incisors  were  moved  inw'ard  by  closing  the  U-shaped 
loops  in  the  semicircular  spring,  dressing  aw^ay  the  anterior  part  of 
the  plate  from  time  to  time.  For  additional  force,  a  cross-bar  like 
Fig.  237  was  worn  at  night  for  about  six  weeks.  Fig.  249  illustrates 
the  improvement  in  the  features  in  five  months. 

Fig.  250.  Miss  S,  aged  fourteen  years.  Excessive  anterior  upper 
protrusion.  Affected  with  nasal  stenosis  since  childhood.  An 
operation  by  a  rhinologist  improved  the  breathing.  The  first  upper 
bicuspids  were  extracted,  and  a  palatine  plate  with  a  semicircular 
spring  \vas  employed  for  moving  the  incisors  and  cuspids  inward 
(Fig.  246).  The  movement  Avas  assisted  by  the  application  of  a 
cross-bar  at  night.  Fig.  251  represents  the  change  in  the  features  in 
seven  months. 

Generally,  in  cases  of  mouth-breathing,  the  lips  are  thick  ;  and 
after  a  rhinological  operation  to  correct  the  breathing,  and  ortho- 
paedic treatment  for  the  correction  of  the  prominence,  it  sometimes 
takes  a  few^  months  for  the  lips  to  settle  against  the  teeth  and  to 
give  a  pleasing  expression. 

Fig.  252.  Miss  N.,  aged  fourteen  years.  The  first  upper  bicus- 
pids were  removed  and  a  palatine  plate  (Fig.  246)  employed.  Sup- 
plemental force  wdth  a  cross-bar  (Fig.  237)  w^as  applied  at  night. 
Fig.  253  illustrates  the  improved  features  in  three  months. 

Fig.  254.  Master  H.,  aged  thirteen  years.  The  first  bicuspids 
were  extracted,  and  the  irregularity  corrected  by  a  palatine  plate 
and  finger-springs  like  Fig.  242.  Supplemental  force  with  the  cross- 
bar was  not  required.  In  Fig.  255  is  seen  the  resultant  improve- 
ment in  the  features. 

Fig.  256.  Miss  B.,  aged  eleven  years.  The  upper  incisors  were 
prominent,  resting  on  the  lower  lip  w^ith  no  spaces  between  the 
teeth.  The  first  bicuspids  w^ere  extracted  and  the  incisors  and  cus- 
pids moved  inward  by  a  palatine  plate  and  finger-springs.  Fig. 
257  sliows  tlic  improved  condition  in  llircc  montlis. 


Fig.  248. 


Fio.  249. 


Fig.  250. 


Fig.  251. 


Fig.  252. 


Fig.  253.   ' 


Fig.  254. 


Fig.  255. 


Fig.  256. 


Fig.  257. 


Fig.  258. 


Fig.  259. 


Fig.  260. 


Fig.  261. 


Fig.  262. 


Fig.  263. 


Fui.  264. 


Fui.  2ii5. 


Fig.  266. 


Fig.  267, 


rPPER   INCISORS,   TO   MOVE  INWARD  243 

Fig.  258.  Miss  G.,  aged  fourteen  years.  Anterior  protrusion. 
The  first  bicuspids  were  removed  and  the  irregularity  was  corrected 
by  a  palatine  plate  and  semicircular  spring.  In  Fig.  259  is  shown 
the  change  in  the  features  in  five  months. 

Fig.  260.  Mr,  C,  aged  seventeen  years.  Mouth-breather.  Case 
of  marked  anterior  protrusion.  Irregularity  corrected  witli  a  pala- 
tine plate  similar  to  Fig.  246.    Fig.  261  shows  the  improved  features. 

Fig.  262.  Miss  P.,  aged  fourteen  years.  The  first  bicuspids  were 
removed,  and  the  protrusion  reduced  with  a  palatine  plate  and  semi- 
circular spring,  as  illustrated  in  Fig.  246,  supplemental  force  being 
given  by  a  cross-bar.  Fig.  263  illustrates  the  improved  condition  of 
the  features  in  five  months. 

Fig.  264.  Master  W.,  aged  twelve  years.  Spaces  between  the 
teeth.  Extreme  protrusion,  with  inability  to  close  the  lips.  The 
irregularity  was  corrected  by  a  palatine  plate  with  a  semicircular 
spring.  In  Fig.  265  is  shown  a  cast  of  the  features  taken  within 
four  months. 

Fig.  266.  Master  N.,  aged  twelve  years.  Upper  arch  prominent 
with  receding  lower  arch.  The  lower  incisors  w^ere  depressed  and 
moved  outward  by  means  of  a  thickened  palatine  plate,  as  shown  in 
Fig.  337,  after  which  the  upper  incisors  were  moved  inward  by  a 
plate  and  semicircular  spring  (Fig.  246).  Supplemental  force  was 
applied  by  a  cross-bar. 

Fig,  267,  Miss  S.,  aged  eight  years.  Mouth-breather  with  nasal 
stenosis.  Extreme  prominence  of  upper  arch.  In  occlusion,  the 
distance  from  the  lingual  side  of  the  upper  incisors  to  the  labial 
side  of  the  lower  incisors  measured  five-eighths  of  an  inch.  The 
breathing  was  improved  by  a  rhinological  operation.  In  correcting 
the  irregularity,  the  first  deciduous  molars  and  the  unerupted  bicus- 
pids were  extracted.  Force  was  exerted  by  a  semicircular  spring 
attached  in  a  thickened  palatine  plate  similar  to  Fig.  338.  Supple- 
mental force  with  a  cross-bar  was  applied  at  night  and  several  hours 
during  the  day. 

Fig,  268.  A  boy  aged  fourteen  years.  This  case  was  presented 
with  models  and  appliances  before  the  Brooklyn  Dental  Society  in 
1889.  The  teeth  in  the  upper  arch  were  very  much  crowded,  and 
protruded  far  beyond  those  of  the  lower,  with  the  lateral  incisors 
projecting  farther  than  the  centrals,  and  all  of  them  needing  to  be 
rotated.     The  teeth  in  the  lower  arch  were  regular  m  their  labial 


244 


INCISORS 


curve,  but  the  incisors  were  on  a  much  higher  plane  than  the  cus- 
pids and  bicuspids,  and  impinged  upon  the  soft  tissues  of  the 
upper  arch. 

The  teeth  being  much  crowded,  the  first  upper  bicuspids  were 
extracted,  which  gave  room  for  moving  the  cuspids  and  incisors 
inward,  to  articulate  with  the  lower  ones. 

Fig.  2G8. 


Fig.  269.  On  June  19  a  vulcanite  palatine  plate  was  inserted, 
thickened  in  its  anterior  portion,  and  fitting  well  the  necks  of  the 
molars  and  bicuspids.  The  plate  was  anchored  with  wire-clasps, 
the  ends  of  which  were  flattened  to  retain  them  in  the  vulcanite. 

Fig.  2m. 


The  free  ends  were  shaped  to  clasp  a  molar  and  bicuspid  on  each 
side  of  the  arch,  with  the  anterior  edge  of  the  plate  shaped  into  a 
smooth  semicircle  somewhat  back  of  the  incisors.  Two  finger- 
springs  of  German  silver  extended  from  the  plate,  one  just  in  front 


UPPER   INCISORS,   TO   MOVE   INWARD 


245 


of  each  of  the  second  bicuspids,  to  tiie  buc(;al  side,  where  the  ends 
of  both  were  bent  forward  to  follow  the  gum,  terminating  on  the 
niesio-labial  surface  of  the  prominent  lateral  incisors.  The  ends  of 
the  springs  were  curved  inward  towards  the  plate  to  give  pressure 

Fui.  270. 


for  moving  the  lateral  incisors  and  cuspids  backward  in  the  circle. 
Fig.  270  represents  the  plate  and  the  extent  of  the  movement  of  the 
teeth  on  July  8.  A  similar  plate  anchored  to  all  of  the  molars  and 
the  bicuspids,  with  longer  fmger-springs  extending  to  the  front  of  the 


Fig.  271. 


arch,  lapping  by  one  another  as  seen  in  Fig.  242,  was  inserted  on 
July  22,  and  the  teeth  were  moved  to  the  position  seen  in  Fig.  271 
on  December  19.     The  force  of  the  springs  on  the  labial  side  of  the 


246 


INCISORS 


incisors  moved  tliein  inward;  at  the  same  time  they  were  pressed 
against  the  edge  of  the  plate,  which  rotated  and  evened  them.  The 
plate  was  dressed  away  from  time  to  time  sufficiently  to  admit  of 
their  inward  movement. 

The  teeth  were  retained  with  a  bar  of  half-round  gold  wire, 
shaped  to  cross  the  labial  faces  of  the  incisors  and  cuspids,  with  the 
ends  of  the  bar  anchored  to  the  second  bicuspids,  as  shown  in  Fig. 
511.  Each  of  the  teeth  rotated  was  held  firmly  to  the  bar  by 
passing  a  small  silver  wire  either  side  of  it,  through  the  interdental 
space  to  the  lingual  side,  and  back  again  on  the  opposite  side  of  the 
tooth,  where  it  was  fastened  to  the  bar. 

Fig.  272  illustrates  the  case  of  a  young  man  eighteen  years  of  age, 

whose  upper  arch  was  inclined  to  be  V-shaped,  Avith  the  teeth  pro- 

FiG.  272.  truding  about  one-half  inch 

beyond  the  lower  ones.* 
The  projecting  teeth  ^vere 
only  partially  covered  by  the 
upper  lip,  giving  an  un- 
pleasant expression. 

The  first  upper  bicuspids 
were  extracted,  and  a  vul- 
canite plate  with  finger-springs  inserted.  The  plate  (Fig.  273)  was 
anchored  with  wire-clasps  to  the  molars  and  bicusi)ids.  For  moving 
the  incisors  and  cuspids  in- 
ward, two  curved  finger- 
springs  extended  from  the 
plate,  one  on  either  side  to 
the  front  of  the  arch,  with 
the  ends  passing  each  other 
as  far  as  the  width  of  one 
of  the  incisors.  As  the 
teeth  did  not  require  to  be 
rotated,  a  jjortion  of  tlie  an- 
terior part  of  the  vulcanite 
was  dressed  away,  but  not 
so  much  as  to  interfere  with  the  anchorage.  Constant  force  was 
exerted  on  the  teeth  by  bending  the  ends  of  the  springs  nearer  to 


Fig.  273. 


*  WiidsworUi,  Denial  Cosmos,  1891,  p.  29. 


UPPER  INCISORS,   TO   MOVE   INWARD  247 

the  plate,  the  increase  l)eing  made  ahout  twice  a  week.  The  teeth 
were  moved  to  articulate  with  the  lower  ones,  as  seen  in  Fig.  274, 
in  about  three  and  one-half  months. 

The  space  between  the  cuspid  and  second  bicuspid  in  this  case 
was  not  fully  closed,  which  illustrates  the  necessity  of  caution  as  to 
the  removal  of  a  first  bicuspid 

^  IiG.  2/4. 

where  it  is  found  from  measure-  .    _ 

ment  that  after  regulation  the 
cuspid  will  occupy  only  a  por- 
tion of  the  space.  However,  the 
removal  of  the  first  bicuspid  is 
usually  recommended.  If  the 
remaining  space  be  excessive, 
the  second  bicuspid  should  be 
moved  forward  and  retained,  and  the  molar  teeth  generally  follow. 

I  do  not  usually  encourage  the  extraction  of  the  second  bicuspids 
or  the  first  molars  wdiere  it  can  be  avoided,  even  though  the  condi- 
tions indicate  it,  as  when  either  of  the  latter  are  removed  it  is  more 
difficult  to  secure  sufficient  anchorage  for  moving  the  front  teeth 
inward.  Fig.  467  illustrates  a  case  in  which  an  operator  extracted 
the  second  upper  bicuspids  with  the  intention  of  lessening  an  anterior 
protrusion  of  the  arch.  The  conditions  were  not  improved  by  the 
extraction,  for  the  molars  gradually  moved  forward  in  the  circle, 
taking  up  much  of  the  space. 

In  correcting  these  conditions  it  was  found  advisable  to  first 
move  backward  the  cuspids  and  first  bicuspids,  and  later  to  move 
the  incisors  inward.  The  anchorage  was  gained  with  a  vulcanite 
plate  covering  tlie  palatine  arch,  fitting  well  to  the  incisor  and 
molar  teeth,  with  wire-clasps  passing  around  the  second  molars. 
The  lateral  side  of  the  plate  opposite  the  bicuspids  and  cuspids 
was  smoothed  to  permit  their  movement.  Finger-springs  were  an- 
chored in  the  plate,  one  on  either  side ;  they  were  shaped  to  extend 
close  to  the  first  molars  near  the  grinding  surface,  through  the  space 
to  the  buccal  side,  and  bent  forward,  terminating  in  a  curve  on  the 
mesio-labial  surface  of  the  cuspids.  The  action  of  these  springs 
curved  tow'ards  the  plate  gradually  moved  the  cuspids  and  bicuspids 
backward,  causing  the  latter  to  rest  in  contact  with  the  molars. 

After  these  teeth  were  in  position  a  similar  plate  was  employed 
with  finger-springs  extending  to  the  front  of  the  arch  for  moving  the 


248  INCISORS 

incisors  inward.  The  springs  passed  from  the  plate  to  the  labial 
side  just  in  front  of  the  cuspids.  Owing  to  the  recent  moving  of  the 
cuspids  and  bicuspids,  it  was  considered  advisable  to  assist  the  an- 
chorage with  a  cross  bar  and  cranial-cap,  as  shown  in  Fig.  237,  it 
being  worn  regularly  at  night. 

When  on  account  of  decay  or  other  cause  it  is  found  necessary  to 
extract  the  first  molars  in  cases  of  anterior  protrusion  in  either  arch, 
it  becomes  necessary  to  move  backward  both  bicuspids  on  each  side 
before  moving  inward  the  anterior  teeth.  This  can  be  accom- 
plished with  apparatus  as  illustrated  in  Figs.  470-475. 

Fig.  275  illustrates  the  case  of  Mr.  K.,  aged  twenty-two  years. 
The  upper  incisors  projected  forward  of  the  lower  ones  five-eighths 

Fig.  275. 


^s^lllilMSf'' 


of  an  inch  by  measurement.  The  distance  was  determined  by 
passing  between  the  upper  central  incisors  a  thin  piece  of  metal 
with  the  end  pressed  against  the  labial  side  of  the  lower  incisors. 
The  metal  was  then  marked  even  with  the  lingual  surface  of  the 
upper  ones.  The  upper  incisors  closed  in  front  of  the  lower  lip,, 
which  gave  the  effect  of  extreme  prominence  of  the  upper  jaw  and 
recession  of  the  lower.  The  plane  of  the  lower  incisors  was  much 
higher  than  that  of  the  bicuspids  and  molars,  and  in  occlusion 
they  impinged  against  the  soft  tissues  of  the  upper  arch.  This 
condition  is  common,  and  should  be  corrected  by  depressing  the 
lower  incisors,  usually  before  moving  the  upper  incisors.  For  this 
purpose  a  plate  covering  the  palatine  arch,  anchored  with  wire- 
clasps  and  thickened  in  the  anterior  portion,  is  employed  (Fig.  338). 
The  pressure  caused  on  Llic  lower  incisors  by  the  natural  action  of 
the  jaws  in  mastication  and  swallowing  gradually  forces  them  more 


UPPER   INCISORS,    TO  MOVE  INWARD  249 

deeply  into  their  alveolar  sockets,  and  at  the  same  tijrne  the  molars 
and  bicuspids,  being  relieved  from  the  pressure  of  occlusion,  become 
elevated.  Generally  the  plate  is  required  to  be  worn  several  months 
for  this  purpose.  When  the  lower  incisors  are  depressed  sufficiently 
the  upper  ones  are  forced  inward  with  the  labial  spring. 

In  this  case  it  was  found  that  if  the  lower  incisors  were  depressed 
and  moved  outward  somewhat  it  would  improve  the  contour  of  the 
features,  and  the  extraction  of  but  one  bicuspid  in  the  upper  arch 
would  be  required.  Accordingly  a  first  left  upper  bicuspid  was 
removed,  and  an  appliance  with  an  inclined  plane  and  springs  in- 
serted. The  incline  was  made  rather  steep  to  force  the  lower  incisors 
outward  and  at  the  same  time  to  depress  them.  In  place  of  the  semi- 
circular spring,  two  curved  finger-springs  extended  to  the  anterior 
part  of  the  arch.  One  of  the  springs  passed  through  the  space 
caused  by  the  extraction  of  the  first  bicuspid,  and  the  other  extended 
from  the  plate  on  the  op})osite  side  over  the  arch  at  the  junction  of 
the  cuspid  and  first  bicuspid.  Slight  changes  only  at  a  time  should 
be  made  in  the  shape  of  the  spring,  the  too  rapid  movement  of  the 
teeth  being  objectionable. 

Fig.  276  illustrates  the  general  appearance  of  the  teeth  after  the 
regulation  was  completed.     They  were  retained  several  months  by 

Fig.  276. 


a  gold  retaining  device,  made  by  forming  a  round  wire  to  follow  the 
labio-buccal  surface  of  the  teeth  near  the  gum  line.  The  ends  were 
attached  by  a  spring-clasp  attachment  for  anchorage  to  the  second 
bicuspids  (Fig.  485). 


250 


INCISORS 


When  upper  or  lower  incisors  appear  too  long,  they  can  be 
depressed  in  their  sockets  (see  Chapter  XV.,  Incisors,  To  depress), 
or  dressed  with  a  carborundum  stone.  (See  Shaping  the  Teeth, 
page  297.) 

Fig.  277  illustrates  the  case  of  a  young  man  sixteen  years  of  age, 
as  presented  for  treatment.     A  first  right  upper  bicuspid  had  been 


Fig.  27 


injudiciously  removed  to  relieve  over-crowded  incisors.  The  left 
upper  lateral  still  remained  very  prominent,  with  insufficient  space, 
and  required  either  the  removal  of  a  bicuspid  on  the  left  side  of  the 
arch,  or  the  movement  of  the  incisors  and  cuspid  towards  the  right 

Fig.  278. 


to  admit,  it  in  tlie  circle.  The  latlor  mctlifxl  was  adopted,  as  it 
would  save  tlie  extraction  of  a  tooth,  and  the  slight  change  in  the 
median  linr-  would  notice  especially  iKjIiccuble. 


UPPER   INCISORS,   TO   MOVE   INWARD 


251 


A  vulcanite  plate  was  made  (Fig-.  278)  covering  the  palatine  arch, 
fitting  well  to  the  necks  of  the  teeth,  and  a  German-silver  wire  was 
carried  from  it  on  each  side  to  surround  a  molar  to  assist  the  anchor- 
age. One  end  of  a  semicircular  spring  was  anchored  in  the 
vulcanite.  It  extended  through  tiie  space  to  the  buccal  side  close 
to  the  mesial  surface  of  the  second  right  bicuspid,  and  was  then 
bent  forward  to  follow  tlie  labial  faces  of  the  incisors  at  the  gum  line 
and  to  cross  the  cuspid  on  the  opposite  side  of  the  arch.  It  was  so 
shaped  as  to  exert  pressure  on  the  prominent  lateral.  The  front 
edge  of  the  vulcanite  was  dressed  away  to  correspond  with  tlie 
position  tlie  teeth  were  to  assume  when  regulated.  The  action 
of  the  appliance  was  controlled  by  bending  the  end  of  the  spring 
closer  to  the  plate  from  time  to  time.  This  procedure  wedged  the 
lateral  hito  place,  forcing  the  incisors  and  cuspid  to  the  opposite 
side  of  the  arch,  and  filling  the  space  of  the  absent  bicuspid. 

The  patient  was  a  student  in  a  college  at  some  distance,  and 
would  not  return  under  three  or  four  months.     He  was  instructed 

Fig.  279. 


to  readjust  the  spring  by  bending  it  a  very  little,  not  oftener  than 
once  in  ten  days  or  two  weeks. 

The  teeth  were  moved  to  the  position  as  seen  in  the  figure  in  a 
limited  time.  The  same  device  was  continued  in  use  as  a  retainer, 
the  pressure  of  the  spring  being  relieved. 

Fig.  279  shows  an  appliance  that  is  serviceable  in  some  cases  for 
moving  inward  the  upper  incisors.  It  is  made  by  fitting  a  palatine 
vulcanite  plate  to  the  necks  of  the  molars  and  bicuspids,  to  \vhich  it 


252 


INCISORS 


is  anchored  with  wire-clasps.  The  front  edge  of  the  plate  is  formed 
into  a  semicircle.  A  tube  of  German  silver  or  other  metal  is 
roughened  and  arranged  in  the  plate  on  either  side  of  the  arch, 
extending  from  the  first  bicuspid,  and  following  the  linguaF  side  of 
the  teeth  to  the  back  part  of  the  vulcanite.  A  small  spring-wire  is 
then  fitted  to  the  labial  side  of  the  teeth  to  be  moved ;  its  ends  are 
curved  to  extend  over  to  the  lingual  side,  back  of  the  cuspids,  where 
they  are  again  bent  nearly  to  a  right  angle,  so  as  to  pass  through  the 
tubes  in  the  plate.  The  ends  of  the  spring  are  provided  with  a 
thread  and  nut,  which  are  turned  to  adjust  the  appliance.  The 
anterior  edge  of  the  plate  is  dressed  away  from  time  to  time  to 
conform  to  the  desired  movement.  A  removable  spring  in  connec- 
tion with  a  plate  has  been  used  in  many  combinations. 

Fig.  280  illustrates  a  case  with  the  upper  incisors  too  prominent, 
and  a  narrow  arch,  which  required  expansion  to  admit  the  incisors 

Fig.  280. 


to  proper  line.  The  appliance  used  tor  expanding  the  arch  was  a  vul- 
canite split  plate  covering  the  palatine  contour ;  it  was  connected  with 
a  U-shaped  spring,  the  plate  being  anchored  with  spring-clasps  over 
a  bicuspid  on  each  side  In  the  front  of  each  of  the  lateral  halves 
of  the  j)late  a  small  tube  was  attached,  resting  longitudinally,  for  the 
purpose  of  supporting  a  spring.  The  tubes  were  made  of  a  narrow 
piece  of  thin  plate-metal ;  the  ends  were  left  one  or  two  lines  in 
length,  and  bent  outward  to  strengthen  their  attachment  in  the 
vulcanite,  A  small-sized  spring-wire  was  formed  to  cross  the  labial 
side  of  the  inci-sors  passing  near  the  gum,  extending  to  the  distal  .side 
of  those  to  be  moved.     The  ends  were  bent  to  pass  over  the  arch 


Fig.  281. 


Fig.  2S2. 


Fig.  283. 


Fig.  2S4. 


INCISORS,   TO    MOVE   INWARD— DOUP.LE   PROTRUSION        253 

at  the  junction  of  the  teeth  near  the  edge,  extending  backward, 
following  the  contour  of  the  plate,  and  bent  sharply  forward  oppo- 
site the  distal  end  of  tlie  tubes,  so  as  to  hook  into  them.  Sometimes 
it  is  preferable  to  cement  the  ends  of  the  springs  in  tiie  tubes,  having 
them  enter  from  the  front.  When  the  arch  was  expanded  laterally, 
force  was  applied  to  move  the  incisors  inward,  bending  the  side- 
arms  of  the  spring  more  acutely  ^vhere  it  passed  over  the  arch. 

The  length  of  the  arms  of  the  si)riug  can  be  shortened  at  any  time 
by  rebending  the  ends  that  enter  the  tubes,  or  recementing  them. 

Thumb-Sucking  a  Cause  of  Upper  Protrusion. — The  habit  of 
sucking  the  thumb  or  fingers  is  begun  early  and  is  sometimes  con- 
tinued after  the  eruption  of  the  permanent  teeth,  producing  upper 
anterior  protrusion.  This  habit  is  occasionally  practised  until  the 
age  of  maturity. 

The  writer  treated  an  interesting  case  for  an  intelligent  girl,  aged 
thirteen  years.  The  habit  had  become  extremely  embarrassing  to 
the  patient  and  her  parents,  as  she  was  accustomed  to  resort  to  it 
unconsciously  at  any  time.  The  upper  incisors  had  become  very 
prominent,  and  the  lower  jaw  receded.  Many  methods  had  been 
employed  to  break  up  the  liabit,  but  none  were  effectual.  With  the 
full  agreement  of  the  })atient,  a  heavy  leather  thumb-cot,  with  a  ser- 
rated leather  strip  attached,  was  applied  to  the  thumb  and  held  in 
place  with  a  lock-chain  bracelet,  as  seen  in  Fig.  281,  and  the  key 
carried  by  the  mother.  By  this  arrangement  the  habit  w-as  soon 
broken,  and  the  teeth  were  regulated  in  the  usual  manner. 

Similar  cots  can  be  used  on  the  fingers  when  required,  or  an 
entire  glove  worn.  With  young  patients  the  habit  can  generally  be 
broken  by  bandaging  the  hand,  or  by  bitter  applications  to  the  fingers 
or  thumb  involved. 

Double  Protrusion  or  True  Prognathism. — In  double  protrusion 
both  the  upper  and  lower  arches  are  too  prominent.  An  apparent 
double  protrusion  is  brought  about  in  some  instances  by  too  short  a 
bite,  the  back  teeth  being  depressed  in  their  sockets  to  such  an  extent 
as  to  cause  the  lips  to  pout.  This  is  usually  corrected  by  opening 
the  bite. 

In  Fig.  282  is  illustrated  the  case  of  Miss  K,,  aged  twelve  years, 
in  which  both  the  upper  and  lower  arches  were  unusually  prominent. 
The  upper  incisors  rested  on  the  lower  lip,  the  lips  being  closed 
with  difficulty.     To  improve  the  facial  line  and  permit  the  natural 


254  INCISORS 

closure  of  the  lips  required  the  inward  movement  of  the  incisors 
and  cuspids  with  the  process. 

To  get  space  for  their  correction  the  first  upper  and  lower  bicus- 
pids were  extracted.  A  palatine  plate  with  curved  finger-springs 
(Fig.  242)  Avas  inserted  in  the  upper  arch,  and  a  metal  appliance 
with  similar  springs  (Fig.  207)  adapted  to  the  lower  arch.  Contin- 
ued pressure  was  exerted  on  the  labial  faces  of  the  incisors  and 
cuspids  with  the  springs.  Supplemental  force  was  applied  to  the 
teeth  of  the  upper  arch  by  means  of  a  cross-bar  device,  as  shown 
in  Fig.  283.  The  latter  was  worn  regularly  at  night,  and  as 
many  hours  as  convenient  during  the  day.  As  the  upper  incisors 
Avere  forced  inward  they  came  in  contact  in  occlusion  with  the 
lower  incisors,  giving  additional  pressure,  which  assisted  in  moving 
them  inward.  The  movement  of  the  teeth  and  process  in  this 
manner  improved  the  facial  line  and  produced  a  pleasing  expression 
(Fig.  284). 

In  double  protrusion,  when  the  incisors  project  beyond  the  lips, 
it  generally  becomes  necessary  to  depress  them  in  their  alveoli. 
Fig.  285  shows  the  features  of  Master  A.,  aged  eleven  years, — a  case 
requiring  the  depression  of  the  incisors  and  the  reduction  of  the 
extreme  prominence.     (See  Chapter  XV.,  Incisors,  To  depress.) 

To  get  space  for  the  reduction  of  anterior  protrusion,  extraction 
of  some  of  the  teeth  is  generally  required.  Usually  the  bicuspids 
are  chosen  ;  but  sometimes,  owing  to  the  poor  structure  of  the  first 
molars,  it  is  advisable  that  they  be  removed  rather  than  either  the 
first  or  second  bicuspids,  even  though  the  extraction  of  the  molars 
lessens  the  anchorage  and  makes  the  regulating  more  difficult.  In 
Fig.  469  is  illustrated  a  case  of  double  protrusion.  The  first  upper 
and  lower  molars,  being  defective,  were  extracted.  The  incisors, 
cuspids,  and  bicuspids  were  forced  backward  closing  the  spaces. 
Owing  to  the  weakened  anchorage  from  the  loss  of  the  first  molars, 
special  apparatus  was  necessarily  devised  for  reducing  the  promi- 
nence of  each  arch.    (See  description  accompanying  Figs.  469-476.) 

Double  protrusion  is  not  infrequently  accompanied  with  a  promi- 
nent lower  jaw  and  thick  lips,  as  in  the  case  of  Miss  D.,  aged 
ten  years.  The  incisors  jjrotruded  beyond  the  lips,  which  were 
closed  with  (lifficiilty,  and  the  lower  jaw  was  gradually  becoming 
more  prognathous.  A  rhinological  operation  improved  the  breath- 
ing.    In  addition  to  appliances  in  the  mouth  for  reducing  the  promi- 


Fig.  285. 


Fig.  286. 


INCISORS,    TO   MOVE   INWARD— DOTTBLE  PROTRUSION        255 

nence  of  the  teeth  and  process  it  was  found  necessary  to  employ 
supplemental  force. 

In  Fig.  286  is  illustrated  the  apparatus  used  for  this  purpose, — a 
chin-cap,  a  supralabial,  and  an  infralabial  bar. 

The  chin-cap  and  wire  standards,  supported  by  a  cranial-cap,  is 
made  as  described  on  page  167.  To  the  metal  on  the  band  of  the 
cap  on  each  side  is  fastened  one  end  of  a  long  tube  extending  down- 
ward in  front  of  the  ear  into  which  the  wire  standard  is  made  to 
pass.  Near  the  lower  end  of  the  tube  is  attached  an  adjustable 
knob  opposite  the  lobe  of  the  ear  for  the  attachment  of  the  supra- 
labial  bar;  two  others  are  adjusted  to  the  standard,  one  a  little 
below  the  end  of  the  tube  for  the  attachment  of  the  infralabial  bar, 
and  the  other  at  the  angle  of  the  standard,  for  the  attachment  of 
an  elastic  from  a  suspender  passing  below  the  ear  to  the  back  part  of 
the  cranial-cap.  Over  this  knob  and  the  knob  on  the  tube  is  attached 
another  elastic.  The  force  of  these  elastics  causes  upward  and  back- 
ward tension  on  the  jaw.  The  infralabial  bar  is  made  as  illustrated 
in  Figs.  213  and  214.  The  supralabial  bar  is  made  in  a  similar 
manner  by  fitting  to  each  of  tlie  teeth  to  be  moved  a  narrow  strip  of 
plate-metal,  bending  it  over  the  edge  and  shaping  it  to  rest  on  the 
labial  and  lingual  sides.  On  the  labial  side  of  the  teeth  the  metals 
may  be  curved  to  pass  over  the  spring  of  the  apparatus  worn  in 
the  mouth,  or  left  straight  to  pass  underneath  it.  After  the  strips 
of  metal  are  arranged  on  each  of  the  teeth  on  the  model  as  desired, 
a  wire,  No.  12  gauge,  is  curved  to  cross  the  metals  on  the  labial 
side  near  the  gum,  with  the  ends  bent  downward  and  forward  to 
pass  between  the  lips  near  the  corners  of  the  mouth,  and  again  bent 
upward  and  backward  to  rest  over  the  cheeks,  forming  arms.  The 
wire  is  then  soldered  to  the  strips  of  metal,  and  a  knob  or  button  is 
attached  to  each  of  the  arms.  If  preferred,  the  supralabial  bar  can 
be  made  as  illustrated  in  Fig.  241,  with  a  cap  passing  over  the  teeth 
(see  description  in  connection  with  71,  c),  to  which  the  bar  is 
pivoted. 

For  causing  force,  rubber  bands  of  suitable  tension  are  hooked 
over  the  knobs  on  the  bars  and  the  adjustable  knobs  on  the  standards. 

When  the  upper  teeth  lap  well  over  the  lower  ones,  force  with  a 
supralabial  bar  is  sufficient  for  moving  inward  both  the  upper  and 
lower  teeth  if  there  is  space  for  their  movement. 


CHAPTER   XIII 

INCISORS,  TO    MOVE   LATERALLY 

The  lateral  movement  of  teeth  is  required  to  close  interdental 
spaces,  to  improve  occlusion,  to  cause  space  for  erupting  teeth,  or 
space  for  the  regulation  of  teeth.  When  there  are  abnormal  spaces 
between  the  incisors,  it  mars  the  personal  appearance  and  interferes 
with  pronunciation;  and  the  malposition  of  the  incisors  sometimes 
prevents  the  eruption  of  the  adjoining  teeth. 

In  Fig.  287  is  illustrated  the  case  of  a  girl  seven  years  of  age. 
The  permanent  upper  central  incisors  were  erupted  with  a  broad 
PiQ  287.  space  between  them,  occupy- 

ing nearly  the  position  of  the 
deciduous  laterals,  the  roots 
■f  of  which    had    become   ab- 

sorbed,  so   that  the  crowns 

,^  .        _.«.    ~^f^     r'~-\~.        cameaway  at  about  the  same 

time  as  the  deciduous  central 


incisors.  In  such  a  case  it  is 
generally  essential  that  the 
permanent  incisors  be  moved 
to  proper  position  before  being  fully  erupted,  and  retained,  as  the 
alveolar  sockets  are  then  large,  and  the  process  of  bone  not  being 
deposited  around  the  necks  of  the  teeth,  they  can  be  brought 
together  more  easily.  Their  movement  at  this  time  is  less  liable 
to  move  the  ends  of  the  roots  in  an  opposite  direction,  which  would 
interfere  with  the  progress  of  the  already  crowded  non-erupted  per- 
manent lateral  incisors.  By  drawing  the  central  incisors  together, 
the  laterals  would  have  the  necessary  space  for  eruption,  and  be 
more  likely  to  take  a  regular  position  in  the  circle  of  the  arch. 

At  this  stage  of  the  eruption,  the  teeth  can  be  moved  so  easily, 
that  there  is  an  inclination  on  the  part  of  the  operator  to  move  them 
more  rapidly  than  is  wise.  A  simple  device  for  their  correction  is 
made  by  cementing  to  each  of  the  incisors  a  collar  with  an  eyelet, 
short  tube,  or  pin,  soldered  in  suitable  po.sition  on  the  labial  surface, 
usually  near  the  distal  side.  A  small  spring-wire  is  bent  into 
2oG 


INCISORS,   TO  MOVE  LATERALLY  257 

a  U-shaped  loop,  arranged  to  point  upward  and  rest  at  tlie  median 
line  between  the  gum  and  the  lip.  The  w'idth  of  the  loop  is  made 
a  little  broader  than  the  space  between  the  teeth  to  be  moved.  The 
ends  of  the  spring  are  bent  outward  to  a  horizontal  line  to  pass 
beneath  and  to  the  outer  side  of  the  eyelets  soldered  to  the  collars, 
where  the  ends  of  the  wire  are  again  bent  upward  and  back  on  itself 
to  hook  into  the  eyelets  or  tubes,  or  encircle  the  pins  described.  It 
Avill  be  seen  from  the  figure,  that  by  removing  the  spring  and  closing 
the  central  U-shaped  loop  slightly  from  time  to  time,  steady  force 
will  be  caused  for  moving  the  incisors  together. 

The  same  device  can  be  continued  in  use  for  retaining,  or  a  small 
wire  can  be  passed  through  the  tubes  or  eyelets,  with  the  ends  bent 
downw'ard.  When  pins  are  used  in  place  of  eyelets  on  the  collars, 
a  small  wire  ligature  can  be  passed  about  them. 

In  the  present  case  the  teeth  w^ere  retained  by  fitting  to  each  of 
them  a  narrow  platina-gold  collar,  united  at  the  median  line  (Fig. 
501)  and  well  cemented  to  the  teeth,  which  was  worn  until  the 
lateral  incisors  were  erupted.  The  device  I  have  descrD^ed  is  also 
used  for  separating  or  rotating  the  central  and  lateral  incisors  by 
changing  the  form  of  the  ends  of  the  spring. 

When  tlie  incisors  are  twisted  inward  the  tubes  or  eyelets  can  be 
attached  to  the  collars  near  the  median  line,  and  the  ends  of  the 
spring  lengthened  to  pass  through  them.  Change  the  spring  from 
time  to  time  by  bending  the  ends  outward  to  cause  pressure.  For 
other  forms  of  springs  and  their  attachment  suitable  for  the  lateral 
movement  of  teeth,  see  Figs.  305-309,  329,  etc. 

Dr.  W.  H.  Jackson  utilizes  a  very  small-sized  spring-wire  for  draw- 
ing together  and  rotating  upper  incisors,  forming  the  wire  into  a 
U-shaped  loop  to  rest  over  the  interdental  space  as  illustrated  in  the 
figure,  and  shaping  the  ends  of  the  spring  to  cross  the  labial  side 
and  to  pass  around  the  incisors  near  the  gum,  once  or  more  than 
once  to  grasp  them.  The  spring  is  removed  and  the  central  loop 
closed  from  time  to  time  for  applying  force. 

Fig.  288  show^s  the  form  of  an  appliance  that  I  used  in  the  case  of 
a  girl  aged  seven  years,  for  forcing  together  two  upper  central  incisors 
with  a  broad  space  between  them,  at  the  same  time  causing  room 
for  a  crowded  erupting  lateral  incisor  that  was  rotated  inward. 

A  second  deciduous  molar  on  each  side  was  chosen  to  anchor  the 
ends  of  a  Ungual  base-wire.     Just  back  of  the  space  between  the 

17 


258 


INCISORS 


Fig.  288. 


central  incisors  a  small  spring-wire  was  soldered  to  the  base-wire, 
its  ends  extending  to  the  distal  and  labial  sides  of  the  incisors  in  the 
form  of  arms.  From  time  to  time  the  shape  of  the  arms  were  changed 
by  bending  them  to  move  the  incisors  together,  thus  closing  the  space 

and  giving  abundant  room  for 
the  proper  eruption  of  the 
lateral  incisors.  The  spring 
did  not  clasp  the  fronts  of  the 
teeth  firmly,  because,  the  in- 
cisors being  of  wedge  shape, 
this  would  have  a  tendency  to 
depress  them  in  their  sockets. 
If  the  permanent  lateral  in- 
cisors are  erupted,  the  arms 
of  the  spring-wire  described 
should  be  bent  in  the  form  of  a  loop  to  extend  over  to  the  labial 
side,  at  the  junction  of  the  central  and  lateral  incisors  near  their 
edge,  as  illustrated  in  Fig.  230.  With  this  style  of  appliance  it  is  not 
necessary  to  cement  collars  to  the  teeth  to  retain  the  spring. 

When  the  incisors  are  too  prominent,  with  spaces  between  them, 
it  is  sometimes  an  advantage  to  construct  an  appliance  with  the  body 
of  the  spring  on  the  labial  side,  as  shown  in  Fig.  477. 

The  device  illustrated  in  Fig.  289  was  used  for  correcting  the 
position  of  the  teeth  in  the  upper  arch  for  a  young  lady  aged  twenty- 
three  years.  The  lateral  in- 
cisors had  never  made  their 
appearance  and  the  cuspids 
had  assumed  a  rather  promi- 
nent position,  with  a  broad 
space  between  them  and  the 
central  incisors.  A  lingual 
base-wire.  No.  14  gauge,  was 
formed  and  anchored  in  the 
usual  manner.  A  spring-wire 
was  united  to  the  base-wire 
at  the  median  line  and  curved 
backward,  with  the  ends  ex- 
tending to  the  labial  side  of  the  cuspids  in  the  form  of  arms,  the 
action  of  which  moved  the  cuspids  into  the  position  of  the  lateral 


Fig.  289. 


INCISORS,   TO   MOVE   LATERALLY  259 

incisors.  Another  spring-  in  the  form  of  an  arm  was  attached  to  the 
base-wire  and  extended  to  the  distal  and  buccal  sidt  of  the  first  right 
bicuspid  for  moving  it  forward  and  inward.  The  same  appliance 
was  used  several  montlis  for  retaining. 

Not  infrequently  cases  are  presented  for  correction — either  the 
child  or  adult — where  from  tlie  history  it  is  learned  that  the  incisors 
are  gradually  moving  farther  apart.  This  may  result  from  an  ab- 
normal developing  fraenum,  excessive  or  continued  intermaxillary 
development,  hypertrophy  of  the  tongue,  or  from  an  erupted  or 
non-erupted  supernumerary  tooth.  When  from  the  latter,  it  should 
be  removed  early ;  if  from  an  over-developed  frienum,  with  its  at- 
tachment extending  through  the  interdental  space  at  the  median 
line,  the  fraenum  should  be  operated  upon. 

In  this,  as  in  some  other  forms  of  irregularity  described,  retaining 
the  teeth  is  of  more  importance  than  the  method  of  moving  them ; 
as,  if  the  same  influences  exist  after  the  teeth  are  regulated,  and  they 
are  not  permanently  retained,  they  are  likely  to  return  to  their  former 
position. 

Dr.  Tomes  and  other  writers  have  described  methods  of  moving 
irregular  teetli  with  the  fingers  by  constantly  pressing  on  them  in 
the  direction  it  is  desired  they  shall  move.     It  is  difficult  to  estimate 

Fig.  290. 


the  value  of  finger  manipulation  in  any  especial  case  of  irregularity, 
but  it  is  remarkable  what  results  can  be  obtained  by  perseverance. 

Fig.  290  illustrates  an  irregularity  that  was  corrected  with  finger- 
pressure  in  the  case  of  a  boy  aged  fifteen  years.     Two  large  super- 


260  INCISORS 

numerary  teeth  occupied  the  position  of  the  upper  central  incisors. 
The  lateral  incisors  were  in  their  normal  position ;  the  central  in- 
cisors were  in  front  of  them,  with  a  space  about  one-fourth  of  an 
inch  between  them,  and  lapping  somewhat  on  to  the  supernumerary 
teeth. 

The  supernumerary  teeth  were  removed,  and  the  lad  was  instructed 
to    press  together   and  inward  continuously    with  the  thumb   and 

Fig.  291. 


fmger  on  the  distal  sides  of  the  centrals.  In  about  twenty  months, 
when  he  was  seen  again,  they  were  moved  to  the  position  shown  in 
Fig.  291. 

,  Several  methods  of  forchig  the  roots  of  the  teeth  towards  each 
other  at  the  same  time  the  crowns  were  being  moved  have  been 


Fig.  292. 


described.     I  have  found  this  to  be  necessary  in  but  a  few  of  the 
many  cases  corrected. 

Fig.  292  illustrates  a  device  for  causing  the  lateral  bodily  move- 
ment of  the  incisors.  To  the  incisors  are  cemonied  broad  collars. 
Two  threaded  bolts  with  nuts  are  attached  on  the  labial  side,  one  to 
each  of  the  collars,  arranged  to  run  jjarallel  and  to  pass  through  a 


INCISORS,   TO   MOVE   LATERALLY 


261 


tube  on  the  opposite  collar.  The  nuts  are  adjusted  and  turned  a 
little  at  regular  intervals  for  causing  the  required  force.  For  further 
details  in  making,  see  Chapter  XVII.  (Incisors,  to  move  Bodily). 

Fig.  293  shows  the  result,  in  the  case  of  Miss  F.,  of  the  too  early- 
extraction  of  the  first  right  upper  deciduous  molar  by  an  injudicious 

Fig.  293. 


operator.  In  consequence  of  the  extraction  the  right  deciduous 
cuspid  had  moved  backward  in  contact  with  the  second  deciduous 
molar,  with  the  permanent  central  and  lateral  incisors  erupted  con- 
siderably to  the  right  of  the  median  line,  with  spaces  between  them. 
The  lateral  being  in  contact  with  the  deciduous  cuspid  left  no  space 
for  the  proper  eruption  of  the  permanent  cuspid.  After  carefully 
considering  the  case  it  was  determined  to  move  the  central  and 
lateral  incisors  towards  the  median  line,  thus  correcting  their  posi- 
tion and  giving  space  for  the  permanent  cuspid.  A  palatine  base- 
wire  was  anchored  with  spring-clasp  attachments  to  the  second 
deciduous  molars  with  partial-clasps  on  the  adjoining  teeth.  To  the 
lateral  on  the  right  side  was  cemented  a  collar  with  a  lug.  A  spring- 
wire  for  moving  the  teeth  was  attached  to  the  partial-clasps  on  the 
left  side ;  it  extended  forward,  following  the  lingual  curve  of  the 
teeth,  being  formed  into  a  U-shaped  loop  projecting  backward  at 
the  median  line.  The  end  of  the  spring  was  curved  backward  to 
pass  under  the  lug  and  terminate  in  a  hook  on  the  distal  face  of 
the  lateral.  The  incisors  were  moved  towards  the  median  line  by 
closing  the  U-shaped  loop  and  bending  the  end  of  the  spring  for- 
ward, thus  giving  the  desired  space  for  the  permanent  cuspid.  The 
same  appliance  was  used  for  retaining.     A  base-wire  device  or  a 


262 


INCISORS 


palatine  plate,  with  spriiiijs  shaped  as  illustrated  in  Fig.  247  can  be 
utilized  for  moving  upper  incisors  laterally. 

In  Fig.  294  is  illustrated  an  appliance  that  was  used  for  correcting 
the  position  of  crowded  lower  incisors,  the  first  bicuspids  having 
been  removed  to  cause  spaces  for  their  accommodation. 

A  lingual  base-wire  was  shaped  to  the  line  the  teeth  should  assume 
when  regulated,  and  anchored  with  partial-clasps  and  spring-clasp 

Fig.  294. 


attachments.  A  semicircular  spring  with  two  U-shaped  loops  was 
arranged  to  cross  the  labial  side  of  the  incisors  and  cuspids  near  the 
gum  and  project  to  the  mesial  surface  of  the  bicuspids,  where  the 
ends  of  the  spring  passed  to  the  lingual  side  to  be  united  to  the  par- 
tial-clasps with  the  base-wire,  the  loops  resting  between  the  gum  and 
the  lip  opposite  the  spaces.  Another  spring  with  two  U-shaped 
loops  was  attached  to  the  front  part  of  the  base-wire  just  back  of 
the  incisors,  the  free  ends  being  shaped  to  project  over  the  arch  to 
rest  on  the  mesio-labial  surface  of  the  cuspids  for  forcing  them  back- 
ward. When  sufficient  space  was  caused,  slight  pressure  was  ap- 
plied on  the  labial  faces  of  the  incisors  by  closing  the  loops  in  the 
semicircular  spring.  The  inward  pressure  forced  the  teeth  against 
the  base-wire,  wedging  them  laterally  and  backward  along  the  curved 
enclosure. 

Fig.  295  illustrates  an  appliance  that  was  utili/.od  in  the  case  of 
Miss  P.,  aged  twelve  years,  fur  moving  laterally  towards  the  right 
the  lower  incisors  and  both  cusjtids.  The  cusjjids  occluded  in  front 
of  the  upper  Icjolh.  TIktc  was  iiisul'ficient  room  for  them  to  take  a 
normal  position  in  the  arch.  Si)ace  was  gained  by  the  extraction  of 
a  first  right  bicus[}i(l.     Tlic  ujjpliance  was  constructed  with  a  lingual 


INCISORS,   TO   MOVE   LATP:RALLY 


263 


base-wire,  its  ends  anchored  by  partial  clasps  to  the  remaining  bicus- 
pids, and  by  spring-clasj)  altachments  to  the  first  molars.  The  right 
cuspid  was  moved  backward  into  the  space  caused  by  the  extraction, 
by  means  of  a  finger-spring  attached  to  the  base-wire.   The  spring  was 


Fin.  205. 


shaped  to  pass  through  the  space  just  in  front  of  the  second  bicuspid 
to  the  buccal  side  of  the  arch,  and  then  forward  in  a  curve,  the  end 
resting  on  the  mesio-labial  surface  of  the  cuspid.  Pressure  was 
caused  by  bending  the  end  of  the  spring  backward  and  towards  the 
base-wire.  By  means  of  another  spring,  attached  to  the  base-wire 
and  partial-clasps  on  the  left  side,  all  of  the  incisors  and  the  left  cus- 
pid were  moved  laterally  towards  the  right,  the  spring  being  shaped 
to  extend  over  the  arch  at  the  junction  of  the  cuspid  and  bicuspid, 
and  curved  forward  to  rest  on  the  labial  side  of  the  cuspid  near  the 
gum.  The  necessary  force  for  moving  the  teeth  was  applied  by 
bending  the  spring  so  that  it  would  rest  nearer  the  base-wire.  This 
applied  force  to  each  of  the  teeth  successively,  moving  them  laterally 
to  the  right,  and  brought  about  an  excellent  occlusion  in  a  short 
time.  When  the  incisors  in  either  the  upper  or  lower  arch  need  to 
be  moved  laterally  to  range  them  properly  at  the  median  line,  or  for 
other  purpose,  generally  lateral  pressure  on  one  of  them,  if  suffi- 
ciently gradual,  and  when  there  is  sufficient  space,  will  move  the 
others  without  crimping  them,  especially  if  they  were  not  originally 
in  an  irrej^ular  line. 


CHAPTER  XIV 

INCISORS,   TO    ROTATE 

The  earlier  procedure  for  rotating  teeth  in  their  sockets  to 
improve  their  appearance  and  the  occlusion  was  the  application  of  a 
cord  ligature,  tying  it  firmly  about  the  tooth  to  be  moved,  and  causing 
traction  in  the  riglit  direction  by  fastening  the  ends  securely  to  one 
or  more  other  teeth  in  the  arch.  Later  the  elastic  ligature  was  used 
to  advantage  in  connection  with  the  cord,  having  adjustable  collars 
over  the  teeth  to  be  moved,  with  spurs  in  the  form  of  posts,  hooks, 
or  tubes  soldered  to  them  for  the  attachment  of  the  ligatures.  A 
properly  fitted  collar  with  a  tube  attached  for  the  introduction  of  a 
spring   bar   has  been    used    many  years  for    rotating,*   and    since 

Fig.  296. 


Mesio-lingual. 


Dis  to-labial. 


Mesio-labial. 


Disto-lingual. 


Movements  in  rntatinn  of  incisors. 

Dr.  Magill  introduced  the  method  of  cementing  collars  to  the  teeth, 
in  1871,  the  collar  with  tlio  lube  and  spring  has  been  almost  univer- 
sally adopted. 

In   the  process  of  rotating  an  iru^isor,  especially  when   the  teeth 


*  Evans,  Dental  News  Letter,  1853,  page  70. 


264 


ROTATION   OF   INCISORS 


265 


Fig.  297. 


are  crowded,  it  is  inclined  to  become  too  prominent.  This  tendency- 
is  usually  counteracted  by  attaching  to  the  lingual  side  of  the  collar 
a  round  or  flat  metal  spur,  to  project  back  of  one  of  the  adjoining 
teeth,  and  applying  the  force  gradually. 

In  the  rotation  of  the  incisors  there  are  four  principal  movements 
to  be  considered.  They  are  referred  to  as  the  meslo-llngual  (rotating 
an  incisor  inward),  the  mesio-lahial  (rotating  an  incisor  outward),  the 
disfo-ldbial,  and  disto-Ungual  rotation  (Fig.  296). 

Rotation  of  Incisors  Mesio-Lingually  or  Disto-Labially. — When 
the  mesio-labial  surface  of  the  right  upper  central  incisor  is  consider- 
ably in  advance  of  the  left  central,  with  nearly  space  enough  for  it  in 
the  arch  (Fig.  297),  its  position  can  be  corrected  by  cementing  to 
it  a  collar  with  a  short  tube  or 
eyelet  soldered  perpendicularly  on 
the  disto-labial  surface,  and  a  spur 
attached  on  the  lingual  side  in 
position  to  project  back  of  the 
lateral,  to  prevent  the  distal  part 
of  the  incisor  from  moving  out- 
ward too  far  during  rotation.  A 
spring-clasp  attachment  for  sup- 
porting a  spring-wire  is  made  for  a 
molar  or  bicuspid  on  the  left  side. 
The  partial-clasp  is  arranged  on 
the  buccal  surface,  the  end  of  the 
spring  is  soldered  to  it  and  shaped 
to  extend  forward,  following  the 
labial  curve  of  the  arch  to  the  tooth  to  be  rotated,  where  the  free  end 
of  the  spring  is  formed  into  a  U-shaped  loop  projecting  towards  the 
gum,  with  the  end  passing  downward  through  the  tube  on  the  incisor, 
as  shown  at  a,  b.  The  spring  can  enter  the  tube  from  either  above  or 
below.  The  tension  for  rotating  is  caused  by  removing  the  appliance 
and  bending  the  end  of  the  looped  spring  outward  slightly  and  press- 
ing it  into  the  tube.  When  the  incisor  is  to  be  rotated  in  an  opposite 
direction,  the  spring  can  be  arranged  on  the  other  side  of  the  arch. 
For  an  obvious  reason,  the  shape  of  the  spring  should  not  be  changed 
between  the  loop  and  the  anchorage  portion  (Fig.  298).  Were  the 
spring  left  straight,  as  from  a  to  6,  with  one  end  entering  the  tube  at 
c,  and  the  other  sprung  back  and  fastened  to  an  anchorage  tooth  ate/, 


266 


INCISORS 


as  is  often  recommended,  the  spring  Avould  not  cease  its  action  until  it 
had  become  straight  again.  Therefore,  if  from  any  cause  the  spring 
was  not  removed  at  the  proper  time,  both  the  incisor  that  was  being 
rotated,  and  the  tooth  used  for  anchorage  would  be  likely  to  be 


moved  far  out  of  the  desired  position,  and  the  outer  curve  of  the 
arch  would  be  flattened  by  its  pressure  on  the  teeth  between  them. 
To  lessen  the  tendency  of  the  appliance  to  move  the  teeth  out  of 
the  natural  curve  of  the  arch  while  being  rotated,  the  following 
device  is  sometimes  adopted.  In  rotating  the  loft  upper  central 
incisor  a  collar  with  a  tube  soldered  horizontally  on  the  labial  side 
should  be  cemented  to  it,  the  collar  being  provided  with  a  s})uron  the 
lingual  side  to  project  on  to  the  lateral  incisor  as  described.  A  spring- 
clasp  attachment  is  fitted  to  a  molar  or  bicuspid  on  the  right  side  of 
the  arch,  with  the  partial-clasp  on  the  buccal  surface.  To  this  is  sol- 
dered a  short  labio-buccal  base-wire,  about  No.  1 9  gauge,  or  large 
enough  not  to  be  springy.  It  is  shaped  to  extend  forward,  following 
tlie  curve  of  the  arch  to  the  right  central  incisor,  to  the  end  of  which 
is  attached  a  small  spring-wire  shaped  to  enter  the  tube  on  the  collar, 
as  seen  in  the  figure.  The  spring  is  made  of  any  springy  metal  de- 
sired, and  is  joined  to  the  end  of  the  base-wire  with  solder,  usually 
first  wrapping  about  thorn   a  narrow,  thin  piece  of  suitable  plate- 


KUTATIOX   OF   INCISORS 


267 


metal ;  or  a  short  piece  of  metal  tubing  can  be  soldered  to  the  side 
or  end  of  the  base-wire  to  liold  the  end  of  the  spring.  The  force 
for  the  rotation  is  caused  by  reshaping  the  spring,  it  being  seldom 
necessary  to  reshape  the  base-wire. 

When  the  conditions  will  permit  it  is  preferable  to  have  the  appli- 
ance for  rotating  arranged  inside  of  the  circle  of  the  arch.  The 
form  of  device  shown  in  Fig.  299  has  some  advantages  over  the  one 

Fig.  299. 


previously  described,  but  it  requires  more  skill  in  manipulation.  It 
is  not  as  unsightly,  may  be  worn  with  less  discomfort  to  the  patient, 
and  while  in  the  process  of  rotation  the  tooth  can  be  moved  inward 
or  outward  as  desired,  to  conform  with  the  line  of  other  teeth  in  the 
arch.  With  this  appliance,  as  in  the  rotating  appliances  arranged 
on  the  labial  side  of  the  arch,  it  is  an  advantage  to  use  a  base-wire 
in  connection  with  the  spring. 

When  the  left  upper  incisor  is  twisted  outward,  with  the  mesial 
surface  much  more  prominent  than  the  right  upper  incisor,  Avhich  is 
in  proper  position,  a  spring-clasp  attachment  for  anchorage  is  made 
for  the  first  or  second  right  bicuspid  or  first  molar,  with  the  partial- 
clasp  arranged  on  the  lingual  side.  To  it  is  soldered  a  base-wire, 
shaped  to  extend  forward  from  the  anchorage,  following  the  lingual 
curve  and  terminating  near  the  incisor  to  be  moved.  To  the  end  is 
attached  with  solder,  or  by  means  of  a  tube,  a  spring-wire  in  the 
form  of  a  loop,  with  the  free  end  of  the  spring  shaped  to  enter  a 
tube  or  eyelet  on  the  lingual  side  of  a  collar  cemented  to  the  incisor 
to  be  rotated. 


268 


INCISORS 


With  this,  as  with  all  appliances  of  this  description,  when  at  rest, 
the  end  of  the  spring-wire  that  is  to  cause  the  tension  in  rotating 
should  be  on  a  plane  with  the  tube  on  the  collar  that  it  is  to  enter. 
To  determine  this  the  appliance  should  be  adjusted  in  the  mouth, 
with  the  spring  by  the  side  of  the  tube ;  we  thus  know  in  each 
instance  that  the  end  of  the  spring  and  the  tube  are  on  the  same 
plane.  At  the  same  time  it  can  be  determined  by  the  position  of  the 
spring  wliether  the  end  is  of  proper  distance  from  the  anchorage 
tooth  to  prevent  the  incisor  from  being  moved  outward  or  inward 
from  the  circle.  If  not,  it  can  be  controlled  by  slightly  curving  the 
looped  portion  of  the  spring  to  shorten  the  distance  from  the  anchor- 
age ;  or  the  base-wire  can  be  straightened  to  lengthen  it.  It  is  es- 
sential that  this  procedure  be  observed.  The  force  for  rotating  is 
caused  by  bending  backward  the  end  of  the  spring  close  Avhere  it 
enters  the  tube. 

In  the  case  illustrated  the  left  lateral  incisor  was  also  twisted,  and 
had  been  rotated  to  position  with  an  appliance  like  the  one  de- 
scribed, although  anchored  on  the  opposite  side  of  the  arch.  At  the 
same  time  an  additional  spring  moved  the  lateral  and  cuspid  back 
into  the  space  previously  occupied  by  the  first  bicuspid.  The  lateral 
incisor  was  retained  by  cementing  to  it  a  collar  having  a  spur  pro- 
jecting from  the  labial  side  on  to  the  cuspid,  and  when  the  central 
Fig.  300.  incisor  was  rotated  to  position 

a  similar  collar  was  cemented 
to  it,  with  a  spur  on  the  mesio- 
lingual  side  projecting  on  to  the 
adjoining  incisor,  and  a  spur  on 
the  labial  side  which  projected 
on  to  the  lateral  incisor  that  had 
been  moved.  (See  Fig.  500.) 
An  easily  manipulated  device 
for  causing  mesio-lingual  rota- 
tion is  illustrated  in  Fig.  300. 
When  a  right  upper  incisor  is 
to  be  rotated,  a  collar  with  a 
Iiorizontal  tube  or  lug  soldered 
on  the  lingual  side  near  the  gum  is  cemented  to  it.  Through  the 
side  of  the  tube  or  lug  near  the  mesial  end  a  hole  is  drilled  for  liie 
accommodation   of  a  looped  spring.     A  spring-clasp  altachiiicnt  is 


ROTATION   OF   INCIBORS 


209 


fitted  to  a  right  molar  or  bicuspid.  To  this  is  attaclied  a  short  Ungual 
base-wire,  extending  forward  and  following  the  curve  of  the  arch  to 
the  lateral  incisor  (a),  where  it  is  joined  with  solder  to  a  small-sized 
spring  which  passes  under  the  end  of  the  lug,  and  is  bent  into  the 
form  of  a  U-shaped  loop  projecting  backward  and  resting  over  the 
gum  (A).  The  free  end  of  the  looped  spring  is  bent  at  an  acute  angle, 
forming  a  hook  to  enter  the  hole  in  the  lug  (c).  Force  is  applied  by 
reshaping  the  looped  spring,  bending  the  free  end  backward  a  little, 
then  hooking  it  to  place. 

If  at  any  time  the  incisor  needs  to  be  rotated  farther  disto-labially, 
the  i)art  of  the  spring  that  passes  under  the  lug  is  sliaped  to  })ress 
outward. 

When  the  lower  incisors  close  near  the  gum  back  of  the  upper 
incisors  in  such  a  manner  as  to  interfere  wdth  the  use  of  a  collar 
with  a  tube  or  lug  on  the  lingual  side  for  rotating,  a  bar  or  arm  can 
be  made  of  a  narrow  strip  of  plate-metal,  about  one-half  inch  long, 
with  one  end  bent  at  an  obtuse  angle  and  soldered  to  the  collar. 
The  other  end  should  i)roject  backward,  following  the  contour  of  the 
gum  and  having  a  hole  in  the  end  for  the  attachment  of  a  spring  (Fig. 
301).     A  spring-clasp  attachment  is  applied  to  one  or  more  molars 

Fig.  301. 


for  anchorage,  and  a  small  spring-wire  made  to  [)roject  from  it  in  the 
form  of  a  U-shaped  loop,  with  a  slight  hook  Jiiade  in  the  free  end 
for  hooking  into  the  bar.     Closing  the  loop  in  the  spring  causes  traction 
on  the  end  of  the  bar,  gradually  rotating  the  tooth  into  position. 
The  mesio-lingual  rotation  of  two  incisors  at  one  time  can  be  ac- 


270 


INCISORS 


complishcd  by  attaching  to  each  a  collar  with  an  arm  on  the  lingual 
side  in  this  manner,  havmg  the  arms  projecting  backward  and  run- 
ning parallel  one  with  the  other.  The  force  for  moving  them  is 
given  by  a  simple  looped  spring,  the  ends  of  which  are  bent  at  right 
angles  and  notched  to  enter  the  holes  in  the  arms.  When  one 
tooth  requires  less  force  for  its  movement  than  the  other,  an  addi- 
tional hole  can  be  made  in  the  arm  closer  to  the  collar,  shorten- 
ing the  purchase,  the  looped  wire  being  shaped  so  that  one  side  is 
longer  than  the  other,  so  as  to  hook  into  the  arm  and  to  correspond 
with  the  change  in  the  length  of  the  arms. 

In  a  case  in  which  I  corrected  a  similar  irregularity  several  years 
ago,  owing  to  the  conical  form  of  the  tooth  the  cement  would  break, 
allowing  the  collar  to  slip.  An  arm  with  a  screw  was  applied,  and 
proved  effective  in  retaining  the  collar  on  the  tooth.  The  lingual 
side  of  an  ordinary  collar  was  thickened  sufficiently  to  form  a  nut ; 
through  it  a  hole  was  drilled  near  the  gum  line  and  a  thread  cut, 
into  which  was  turned  a  good-sized  bar  provided  with  a  thread. 
The  free  end  of  the  bar  was  flattened  and  a  hook  made  to  hold  a 
rubber  band  or  cord  that  extended  from  it  around  a  bicuspid  for 
causing  traction.  The  collar  was  set  with  oxyphosphate  of  zinc, 
and  the  screw  turned  as  tight  as  practicable  before  the  cement  had 
time  to  harden.  The  hole  in  the  collar  should  be  made  at  an  angle 
YiG,  302.  to   hold   the  end  of  the  arm 

well  up  in  the  palatine  arch, 
otherwise  the  bar  must  be 
bent. 

This  patient  was  about 
twenty-two  years  of  age,  and 
the  tooth  moved  very  hard. 

A  removable  retaining  de- 
vice, made  as  seen  in  Fig. 
493,  was  worn  at  night  for 
about  four  years, 
A  simple  and  effective  method  of  rotating  into  proper  line  central 
incisors  that  are  partly  or  fully  erupted  is  illustrated  in  Fig.  302. 
On  one  or  both  incisors  a  collar  is  placed  with  lugs  attached 
to  hold  a  U-shajx'd  spring-wire,  with  one  arm  of  the  wire  passing 
across  the  labial  side  of  the  teeth,  ending  in  ii  curve  in  shape  to 
press  on  the  mesio-labial  surface  of  the  incisor  to  be  rotated.     This 


/  ^' 


ROTATION  OF  INCISORS  271 

form  also  keeps  llie  spring  Irom  sli[)piiig  laterally.  The  end  of  the 
other  arm  on  the  lingual  side  is  curved  back  from  the  centre,  and 
reaches  a  little  beyond  the  distal  side  of  the  tooth  to  be  moved. 
The  case  illustrated  was  that  of  a  girl  aged  seven  years.  When  the 
laterals  are  present,  the  looped  end  of  tlie  wire  should  be  bent  up- 
ward at  a  right  angle,  to  pass  over  the  arch  at  the  junction  of  the 
lateral  and  central  incisor. 

The  action  of  the  appliance  is  controlled  by  removing  the  spring 
and  bending  the  ends  towards  one  another. 

In  cases  where  there  is  insufficient  space  it  is  often  hard  to  rotate 
the  teeth  into  proper  position.  Usually  the  operation  is  fticilitated 
by  arranging  an  appliance  to  cause  pressure  on  both  tlie  labial  and 
lingual  sides. 

Fig.  303  illustrates  a  device  made  by  forming  a  simple  spring 
wire  to  pass  around  the  first  molar  and  second  bicuspid  at  the  gum 
line  for  anchorage ;  the  ends  extend  forward,  conforming  to  the  shape 
of  the  gum,  and  terminate  in  a  slight  hook,  pj^,  3Q3 

one  on  the  labial  and  the  other  on  the  lingual 
side  of  the  tooth  to  be  moved.  The  lateral 
sides  of  the  spring  are  connected  with  two 
bars  of  wire  formed  to  extend  over  the  arch 
at  the  junction  of  two  of  the  anchorage  teeth, 
with  the  ends  flattened,  curved  around  the 
wire,  and  soldered.  Partial-clasps  should 
usually  be  applied  to  improve  the  anchor- 
age. 

A  collar  with  small  depressions  or  sockets  near  the  mesio-labial 
and  disto-lingual  sides  to  engage  the  ends  of  the  spring  is  cemented 
to  the  tooth  to  be  rotated.  The  depressions  or  sockets  on  the  collar 
are  generally  made  by  soldering  to  it  a  U-shaped  piece  of  small  wire. 
Force  for  rotating  is  caused  by  curving  the  ends  of  the  spring  to 
proper  form  to  be  sprung  into  the  sockets. 

When  the  teeth  are  crowded,  and  especially  when  the  lateral 
incisor  is  to  be  rotated  at  the  time  of  the  eruption  of  the  cuspid,  it  is 
usually  well  to  rotate  the  lateral  farther  than  its  appearance  would 
seem  to  require,  and  to  retain  it  in  that  position  for  a  considerable 
length  of  time.  This  allows  the  cuspid  to  shrink  farther  into  the 
arch,  where  the  shape  of  its  root  and  that  of  the  lateral  favors  a 
better  approximation. 


272 


INCISORS 


Fig.  304  shows  a  device  applicable  for  the  rotation  of  any  of  the 
teeth.  The  principle  was  utilized  for  the  mesio-lingual  rotation  of 
a  crowded  right  upper  lateral  incisor  for  Mr.  K.,  aged  twenty-four 
years.     A  collar  was  fitted  to  the  lateral;  to  the  lingual  side  of  the 

Fig.  304. 


collar  Avas  attached  a  small  spring-wire  bent  into  a  narrow  U-shaped 
loop  having  a  long  and  a  short  arm.  The  short  arm  was  shaped  to 
pass  just  back  of  the  cuspid.  The  long  arm  followed  the  lingual 
curve  of  the  same  side  of  the  arch,  extending  backward  as  far  as  the 
second  molar,  and  was  anchored  with  a  hook  on  a  collar  cemented 
to  the  first  molar.  The  necessary  force  for  rotating  was  given  by 
unhooking  the  long  arm  of  the  spring,  bending  it  outward  near 
where  it  was  soldered  to  the  collar,  and  springing  the  end  back 
again  under  the  hook  of  the  anchorage.  Only  a  few  visits  were 
required  to  complete  the  rotation. 

In  connection  with  the  methods  mentioned  for  the  rotation  of 
individual  teeth  will  be  described  some  of  the  more  important 
methods  I  have  devised  for  the  rotation  of  two  teeth  at  one  time. 
Fig.  305  illustrates  a  device  for  the  disto-labial  rotation  of  two  upper 

Fig.  .30.'). 


lateral  incisors.  To  each  of  the  lalerals  i.s  cementinl  a  collar  with  a 
short  tube  or  eyelet  attached  across  it  near  the  disto-labial  surface. 
A  small  spring  of  suitable  leiiglh  is  sliai)e(l  to  lit  the  laljial  side  of 
the  incisors,  Avilh  each  end  terminating  in  a  U-s1kij)('(1  looj),  resting 
on  the  lateral,  usually  i)rojecting  U]>ward,  the  ends  or  outer  part  of 


ROTATION   OF   I.N'CISORS  273 

the  loops  being  parallel  with  and  made  to  enter  the  tubes  on  the 
collars  from  above  downward.  Force  is  caused  by  bending  forward 
the  outer  arms  or  sides  of  the  loops  of  the  spring  before  inserting 
the  ends  into  the  tubes,  having  them  parallel,  changes  being  made 
as  required. 

When  only  on*-  incisor  is  to  be  rotated,  the  device  can  be  arranged 
in  the  same  manner,  excepting  that  the  tube  should  be  attached  to 
the  centre  of  the  collar  on  the  tooth  used  for  anchorage.  This  prin- 
ciple is  applicable  to  any  similar  device. 

For  preventing  the  spring  from  slipping  out  of  the  tubes  in  this 
and  in  some  of  the  following  devices,  the  part  that  enters  the  tube 
can  be  curved  slightly  before  being  forced  into  the  tube,  the  spring 
notched  on  the  side  that  is  to  be  pressed  outward,  in  such  a  manner 
as  to  catch  below  the  end  of  the  tube,  or  the  tube  compressed  a  little. 

Fig.  306  represents  a  device  that  was  utilized  for  rotating  two 
incisors  and  at  the  same  time  causing  lateral  traction  for  closing  a 
broad  interdental  space  in  the  case 
of  Miss  T.,  aged  eleven  years.  A 
collar  was  adjusted  to  each  of  the 
incisors,  with  an  eyelet  or  a  very 
short  tube  soldered  to  it,  arranged 
perpendicularly,  and  located  near  the 
disto-labial  surface  of  the  tooth  when 
the  collar  was  cemented  to  place.  A 
small  spring-wire  was  formed  into  three  successive  U-shaped  loops, 
the  ends  shaped  to  rest  parallel  with  the  tubes  and  enter  them  from 
above  downward.  The  force  was  applied  from  time  to  time  by  re- 
moving the  spring  and  bending  the  ends  forward  a  little.  The  space 
between  the  teeth  was  closed  by  narrowing  slightly  the  centre  loop 
of  the  spring. 

If  tubes  are  used  for  this  purpose  they  should  be  short,  and  the 
ends  of  the  spring  when  at  rest  made  parallel  with  them.  When  one 
tooth  is  longer  than  the  adjoining  one,  this  device  can  be  utilized  for 
harmonizing  their  length,  by  having  the  tubes  on  the  collars  rather 
long,  and  properly  shaping  the  spring  by  bending  both  ends  towards 
the  right  a  little,  keeping  them  parallel,  or  towards  the  left  as  required, 
and  pressing  them  into  the  tubes.  Force  applied  in  this  manner 
elevates  one  tooth  and  depresses  the  other. 

When,  in  the  process  of  rotation,  the  hicisors  are  inclined  to  move 

18 


274  INCISORS 

outward,  it  can  be  prevented  by  soldering  to  the  lingual  side  of  each 
of  the  collars  a  spur  projecting  back  of  the  laterals. 

Fig.  307  illustrates  a  similar  device  for  rotating  disto-labially  two 
upper  central  incisors.      It  is  made  by  cementing  to   each  of  the 

Fig.  307. 


incisors  a  collar  with  a  small  tube  attached  horizontally  on  the 
labial  side,  having  one  end  of  the  tube  even  with  the  distal  surface 
of  the  tooth.  A  hole  is  drilled  through  the  sides  of  each  of  the 
tubes  from  below  upward,  the  location  of  the  holes  being  near  the 
distal  end  of  the  tubes.  A  small  wire  is  bent  as  described  into  three 
U-shaped  loops;  their  ends  are  left  parallel,  at  the  proper  distance 
apart  to  enter  the  holes  drilled  in  the  tubes.  The  width  of  the 
centre  loop  in  the  wire  should  be  broad  enough  to  reach  on  to  the 
mesio-labial  surface  of  each  of  the  incisors,  with  the  end  of  the  loop 
rather  near  the  incisive  edge,  and  the  sides  extending  upward  near 
the  gum.  The  ends  of  the  spring  should  usually  be  passed  through 
the  holes  in  the  tube  from  above  downward  and  left  long  to  prevent 
accidental  removal.  Any  tendency  of  the  spring  to  slip  out  of  the 
tubes  is  prevented,  when  necessary,  by  cutting  slight  notches  in  the 
side  of  the  wire  where  it  passes  through  the  tubes,  or  by  bending 
the  ends  of  the  spring  slightly  outward  or  towards  each  other.  The 
necessary  force  for  rotating  the  teeth  is  given  by  removing  the  spring 
and  bending  the  ends  of  the  outer  loops  forward.  When  the  teeth 
are  in  correct  position,  a  slightly  curved  bar  can  be  passed  through 
the  tubes  for  retaining. 

In  Fig.  308  is  shown  a  double  rotating  device  that  has  the  advan- 
tage of  a  spring  with  a  longer  loop  projecting  up  under  the  lip.  It 
is  more  springy  and  does  not  need  to  be  changed  as  frequently  as  a 
shorter  one.  It  also  admits  of  the  lateral  movement  required  for 
hooking  into  or  around  the  end  of  the  tubes. 


ROTATION  OF  INCISORS 


275 


Fig.  308. 


To  each  of  the  incisors  is  cemented  a  collar  having  a  tube  soldered 
horizontally  on  the  labial  side,  with  a  notch  cut  in  the  distal  end 
near  the  laterals.  The  spring-wire, 
formed  into  a  U-shaped  loop,  is 
made  to  rest  underneath  the  lip  at 
the  median  line.  The  ends  ex- 
tending downward  are  bent  out- 
ward at  a  right  angle  to  cross  the 
front  of  the  incisors,  parallel  with 
and  below  the  tubes.  Each  end  is 
then  bent  back  on  itself,  terminating 
in  a  hook-shape  to  catch  into  the 
notches  and  rest  above  the  tubes, 
or  the   ends  of  the   spring  can  be 

made  to  hook  slightly  into  the  tubes  when  preferred.  Force  for  the 
rotation  is  applied  by  bending  the  ends  of  the  spring  outward  a 
little  at  a  time  before  its  adjustment. 

This  form  of  device  can  be  utilized  also  for  drawing  the  teeth  to- 
gether, for  separating  them,  or  for  equalizing  the  length  of  the  incisors 
when  one  appears  longer  than  the  other.  For  the  latter  purpose  it  is 
usually  advisable  to  leave  the  ends  of  the  hooked  portion  of  the  spring 
rather  long,  causing  the  hooks  to  pass  either  side  of  the  tubes,  and  ad- 
justing the  lateral  arms  in  a  manner  to  draw  slightly  upward  on  one 
tooth  and  downward  on  the  other.  I  have  attained  a  certain  degree 
of  success  with  this  device  in  moving  incisors  bodily  together. 

Fig.  309  illustrates  a  simple  appliance  for  double  rotation  of  the 
incisors  mesio-lingually.     It  is   made  by  fitting  to  each  of  them  a 

broad  collar,  to  the  labial  side  of  which  is 
soldered  a  narrow  strip  of  j^late-metal, 
made  on  a  form,  and  bent  approximately 
to  a  rectangular  shape,  thus  making  an 
opening  crosswise  of  the  collar,  and  a  little 
narrower  at  the  lower  edge.  Each  end  of  a 
small  spring-wire  of  suitable  length  is  bent 
into  a  U-shaped  loop  to  enter  the  openings.  The  part  of  the  spring 
between  the  loops  is  slightly  curved  or  corrugated  to  meet  the  changes 
in  rotation.  Force  is  applied  by  bending  forward  the  looped  por- 
tions, they  being  retained  in  the  openings  by  slightly  bending  the 
ends  outward. 


Fig.  309. 


276 


INCISORS 


Fig.  310. 


It"  the  incisors  are  inclined  to  move  outward,  it  can  be  prevented 
by  soldering  to  tlie  lingual  side  of  each  of  the  collars  a  spur  to  pro- 
ject back  of  the  laterals. 

"When  the  upper  central  incisors  have  taken  the  position  com- 
monly found  in  the  V-shaped  arch,  with  their  mesial  surfaces  pro- 
jecting outward  and  with  insufficient  space,  the  device  seen  in 
Fig.  310  is  generally  effective  for  causing  their  rotation  and  prevent- 
ing them  from  being  driven 
forward  of  the  lateral  in- 
cisors. It  is  made  by  fitting 
a  thin,  broad  collar  to  each 
of  the  incisors,  to  which  they 
are  finally  cemented,  having 
a  wire  spur  soldered  to  the 
front  of  each,  reaching  across 
the  median  line,  one  above 
the  other.  An  eyelet  made 
of  wire  or  a  short  section  of 
tube  is  soldered  on  the  disto- 
lingual  side  of  the  collars  near  the  gum,  through  which  a  spring-wire 
is  passed,  leaving  tlie  ends  of  the  spring  long  to  prevent  the  distal 
side  of  the  incisors  from  moving  outward  beyond  the  laterals.  A 
silk  or  elastic  ligature  is  passed  between  the  incisors  and  around  the 
spurs  on  the  labial  side  and  the  spring  on  the  lingual  side  once  or 
more  than  once,  according  to  the  force  rec{uired,  and  fastened. 

Fig.  311  shows  a  fixed  device  for  causing  double  rotation,  and 
at  the  same  time  wedging  the  Fig.  311. 

upper  central  incisors  between 
the  laterals  when  there  is  in- 
sutficient  space.  It  is  made 
with  a  broad  collar  fitted  to 
each  of  llic  Icutli  to  be  moved. 
An  elbow-shaped  small  sjiring- 
wire  is  attacliod  with  solder  to 
the  lingual  side  of  each  collar 
near  the  gum.  One  end  of 
each  wire  is  mad(!  to  extend 
outward  to  rest  r)ii  the  lahTul  incisor;  llu;  other  end  extends  back- 
ward about  half  an   inch  at  Ilic  incdiaii   line,  niore  or  less,  follow- 


ROTATION   OF   INCISORS 


277 


ing  the  contour  of  the  gum,  nmiiiiig-  ijarallel  with  tlK;  spring  project- 
ing from  the  opposite  coHar  anil  resting  one  against,  the  other.  The 
surface  of  tlie  spring  arms  should  be  flattened  a  little  near  the  end 
where  they  rest  together,  or  one  of  them  grooved  to  prevent  their 
passing  by  one  another. 

Force  for  Uie  rotation  of  the  teeth  is  i)roduced  by  springing  one  of 
the  arms  below  the  other,  bending  them  towards  the  opposite  side  of 
the  arch  a  little,  and  springing  them  back  again  to  rest  in  contact. 

Fig.  312  illustrates  the  case  of  Master  B.,  aged  eleven  years,  in 
which  both  upper  lateral  incisors  had  erupted  with  their  lingual  faces 

Fig.  312. 


towards  one  another,  and  their  edge  crossing  the  lower  arch,  resting 
between  the  lateral  mcisors  and  cuspids. 

Their  position  was  corrected  by  rotating  them  hito  the  proper 
circle  with  a  device  as  shown  in  the  figure.  A  collar  was  cemented 
to  each  of  the  laterals,  having  a  tube  soldered  near  the  gum  on  the 
lingual  side.  A  spring- wire  w-as  then  bent  into  several  corrugations 
or  loops  about  one-fourth  of  an  inch  long,  the  ends  of  two  of  the 
loops  pointing  forward  near  the  central  incisors.  The  ends  of  the 
spring  were  also  bent  forward  and  left  long  enough  to  reach  through 
the  tubes  attached  to  the  teeth  to  be  rotated.  Force  w^as  caused 
by  removing  the  spring  from  the  tubes  from  time  to  time,  opening 
slightly  with  round-nosed  pliers  each  of  the  two  loops  that  pointed 
forward,  and  replacing  the  spring.  It  will  be  observed  that  the  dis- 
tance between  the  distal  faces  of  the  lateral  incisors  increased  as 
they  were  rotated  more  nearly  to  a  correct  position.  By  opening 
the  loops  in  the  spring  as  described,  its  length  was  correspondingly 
increased,  at  the  same  time  giving  the  required   force.     When  the 


278 


INCISORS 


rotation  of  the  lateral  incisors  was  nearly  completed  it  became  neces- 
sary to  still  further  lengthen  the  spring,  which  was  accomplished  by 
opening  the  central  loop,  pointing  backward  at  the  median  line. 
When  the  teeth  were  in  correct  position,  the  wire  had  assumed  the 
sliape  seen  in  Fig.  313,  the  same  spring  being  used  to  complete  the 

Fig.  313. 


double  rotation.  As  the  size  of  the  wire  was  small,  its  elasticity  per- 
mitted its  easy  removal  and  replacement  in  the  tubes.  For  retaining, 
a  slightly  curved  Avire  was  passed  through  both  of  the  tubes  and 
worn  for  several  months.  In  the  mean  time,  through  an  accident, 
the  patient  fractured  the  crown  of  one  of  the  central  incisors  at  the 
junction  of  the  lower  third  of  its  length,  and  an  apparatus  as  seen 
in  Fig.  355  was  constructed  to  elevate  it  to  compare  in  length  with 
the  adjoining  incisors. 

Generally  less  skill  is  required  in  the  manipulation  when  two 
springs  are  employed  for  rotating,  as  shown  in  Fig.  314.  Each  spring 
has  a  short  arm  to  enter  the  tube  on  the  collar,  and  a  long  arm  to 
extend  across  the  median  line,  resting  beside  the  long  arm  of  the 
opposite  spring,  and  held  to  it  by  a  hook ;  this  is  made  by  soldering 
to  the  long  end  of  each  of  the  springs  a  narrow  strip  of  plate-metal, 
Fig.  314.  Fig.  315. 


shaped  to  hook  freely  around  the  other,  through  which  it  can  slide. 
The  short  arms  of  the  spring  are  bent  towards  one  another  from 
time  to  time  for  causing  the  desired  movement  and  readjusted.  Two 
springs  iniitcd  in  this  manner  are  suitable  for  rotating  teeth  in  the 
opiiosite  direction  (Fig.  315),  and  can  be  made  to  enter  tubes  arranged 
on  either  the  labial  or  lingual  side  of  the  teeth. 


ROTATION  OF  INCISORS  279 

In  Fig.  316  is  shown  the  form  of  an  appHance  employed  for  ro- 
tating and  moving  inward  to  Hne  projecting  upper  incisors.  At  the 
same  time  both  cuspids,  that  were  very  prominent  and  not  fully 
erupted,  were  moved  backward  into  spaces  provided  by  the  extraction 

Fig.  316. 


of  the  first  bicuspids.  The  central  and  lateral  incisors  lapped  over 
one  another,  as  is  frequently  seen  in  the  V-shaped  arch. 

The  appliance  was  constructed  by  first  arranging  a  lingual  base- 
wire  back  of  the  incisors,  shaping  it  in  the  circle  it  was  desired  they 
should  assume  when  regulated.  The  ends  were  anchored  with 
spring-clasp  attachments  in  the  usual  manner.  The  cuspids  were 
moved  backward  with  finger-springs  which  passed  from  the  partial- 
clasps  to  the  buccal  side,  through  the  spaces  just  in  front  of  the 
second  bicuspids,  and  extended  forward,  terminating  in  the  form  of 
a  slight  hook  on  the  labio-mesial  surface  of  the  erupting  cuspids. 
Force  was  caused  by  curving  the  ends  of  the  springs  inward  towards 
the  base-wire,  and  shortening  them  as  the  teeth  were  moved  back- 
ward. The  position  of  the  incisors  was  corrected  by  a  semicircular 
spring,  shaped  to  press  on  the  labial  side  at  about  midway  between 
their  incisive  edge  and  the  gum.  The  ends  of  the  spring  passed 
through  the  spaces  caused  by  the  removal  of  the  first  bicuspids  and 
were  attached  to  the  base-wire  with  the  other  springs. 

In  designing  the  appliance,  the  width  of  the  incisors  should  first 
be  obtained  with  dividers,  and  spaced  off  on  the  model  in  front  of  the 
circle  to  be  occupied  by  the  base-wire.  In  this  manner  the  proper 
location  for  the  attachment  of  the  ends  of  the  semicircular  spring 
to  the  base-wire  can  be  easily  obtained,  it  being  necessary  to  leave 


280 


INCISORS 


spaces  between  the  distal  side  of  the  laterals  and  the  attachment  of 
the  ends  of  the  spring,  to  permit  the  teeth  to  be  moved  in  contact 
with  the  base-wire.  The  force  for  moving  the  incisors  inward  and 
rotating  them  is  caused  by  straightening,  a  little  at  a  time,  the  part 
of  the  spring  that  rests  on  the  mesial  and  labial  surface  of  the  incisors, 
and  at  the  same  time  curving  a  little  more  the  part  of  the  spring  that 
passes  beyond  the  laterals.  If  there  is  any  excess  in  the  length  of 
the  spring,  it  can  be  taken  up  by  curving  this  part  downward,  or 
forming  a  partial  loop  in  the  anterior  part.  The  continued  pressure 
of  the  spring  on  the  labial  side  and  the  base-wire  on  the  lingual  side 
of  the  teeth  in  this  manner  smooths  out  their  irregularity  and  forces 
them  into  a  correct  circle.  The  cuspids  should  be  moved  a  little  in 
advance  of  the  incisors. 

In  this  case  the  regulating  was  begun  on  February  1,  and  on  April 
6  the  teeth  were  in  the  positiDii  shown  in  Fig.  317,  there  having 

Fig.  317. 


been  eight  visits.  The  position  of  the  cuspids  was  improved,  and 
the  appliance  was  worn  to  retain  the  teeth  until  November  23,  when 
a  retaining  device  (Fig.  486)  was  inserted,  the  patient  being  directed 
to  wear  the  retainer  for  two  years,  and  to  remove  and  cleanse  it  and 
the  teeth  regularly  at  least  once  a  day. 

When  the  incisors  are  in  a  rotated  position  similar  to  those  shown 
in  this  case,  and  need  to  be  made  more  prominent  to  form  a  proper 
circle,  in  some  instances  a  labio-buccal  base-wire  can  be  used  to 
advantage.  It  should  be  suitably  curved,  and  its  ends  anchored 
with  spring-clasp  attachments,  with  one  or  more  finger-springs 
attached  in  a  manner  to  extend  to  llic  lingual  side  of  the  incisors,  so 


KOTATIOX   OF  INCISORS 


281 


as  to  force  them  outward  in  contact  with  the  base-wire.  Many 
exaniph'S  of  rotation  of  the  teeth  by  means  of  force  applied  to  the 
labial  and  lingual  side  Avill  ])e  found  in  other  chapters. 

In  Fig.  318  is  shown  the  form  of  an  appliance  that  has  been  used 
for  moving  inward  prominent  upper  incisors,  and  at  the  same  time 

Fig.  318. 


rotating  them,  in  cases  where  the  lower  incisors  close  against  the 
gum.  Owing  to  this  occlusion  of  the  teeth,  there  is  no  room  for  a 
base-wire  in  its  usual  position  near  the  lingual  side  of  the  incisors. 
It  should  therefore  be  placed  far  enough  back  to  permit  the  lower 
incisors  to  close  in  front  of  it,  and  a  thin  piece  of  metal  to  be  soldered 
to  the  base-wire  resting  on  the  gum  and  projecting  to  the  lingual  side 
of  the  teeth,  first  liaving  the  outer  edge  of  the  metal  shaped  into  tlie 
circle  it  is  intended  the  teeth  shall  form.  The  ends  of  the  base  wdre 
are  held  with  spring-clasp  attachments,  being  anchored  to  all  of  the 
available  teeth.  In  this  case,  there  being  no  spaces  between  the 
teeth,  room  for  their  correction  was  gained  by  the  extraction  of  the 
left  upper  first  bicuspid ;  and  all  of  the  incisors  and  the  cuspids  were 
moved  towards  that  side.  The  left  cuspid  was  first  moved  backw^ard 
with  a  finger-spring;  this  extended  from  the  base-wire  through  to 
the  buccal  side,  next  to  the  second  bicuspid,  and  passed  forw^ard 
ending  in  a  curve  on  the  mesio-labial  surface  of  the  cuspid,  the  end 
being  bent  inward  towards  the  base-wire  to  produce  the  pressure. 
A  long  semicircular  spring  was  shaped  in  a  suitable  curve  to  cross 
the  labial  side  of  all  of  the  incisors  about  midway  between  their 
edge  and  the  gum.  It  had  a  loop  opposite  the  cuspid  on  either 
side,  projecting  up  under  the  lip;  on  the  left  the  loop  passed  over 


282  INCISORS 

the  canine  ridge  considerably  above  the  hne  of  the  gum,  and  was 
made  broad  to  reach  from  the  distal  side  of  the  lateral  to  the  mesial 
side  of  the  second  bicuspid,  where  the  end  jDassed  through  the  space 
and  was  attached  to  the  base-wire.  The  loop  on  the  right  side 
was  made  smaller,  and  projected  upward  only  to  the  margin  of 
the  gum,  reaching  from  the  distal  side  of  the  lateral  to  the  mesial 
side  of  the  first  bicuspid,  where  it  passed  over  the  arch  at  the  junc- 
tion of  the  bicuspid  with  the  cuspid,  to  be  attached  to  the  base-wire. 
The  necessary  force  for  moving  the  teeth  w^as  applied  by  occasionally 
closing  slightly,  with  flat-nosed  pliers,  the  larger  loop  in  the  circular 
spring  that  crossed  the  labial  side  of  them.  This  forced  the  teeth 
inward  against  the  metal  on  the  lingual  side,  and  the  squeezing 
pressure  quickly  rotated  them  into  a  correct  circle.  The  right  cus- 
pid w^as  pressed  into  line  by  bending  inward  the  end  of  the  loop  as 
desired. 

Rotation  of  Incisors  Mesio-Labially  or  Disto-Lingually. — The 
rotation  of  the  incisors  outward  or  mesio-labially  w'ith  the  ordinary 
appliance  is  not  so  easily  accomplished  as  their  movement  in  the 
opposite  direction. 

Fig.  319  illustrates  a  device  adjusted  for  the  rotation  of  a  right 
upper  central  incisor.     A  broad  collar,  with  a  spur  on  the  lingual 

Fig.  320. 


side  projecting  back  of  the  lateral,  and  with  two  short  tubes,  one 
located  near  the  disto-labial  and  the  other  near  the  mesial  surface,  is 
cemented  to  the  irregular  tooth.  A  small  spring-wire  is  shaped  into 
a  long,  narrow  loop  with  one  arm  shorter  than  the  other.  The 
looped  part  is  arranged  to  cross  an  adjoining  tooth,  and  each  end 
bent  at  a  right  angle  towards  the  other  to  enter  the  tubes;  the  dis- 
tance between  these  ends  sliould  be  a  little  less  than  the  distance 
between  the  openings  in  the  tubes.  The  short  arm  is  bent  upward 
and  again  downward  at  a  right  angle  to  enter  the  tube  at  a,  causing 
the  arm  to  extend  on  a  line  with  the  centre  of  the  tube,  or  lower, 


ROTATION   OF  INCISORS  283 

which  is  an  advantage  in  adjusting  the  device.  The  long  arm  ex- 
tends in  a  slight  outward  curve  across  the  teeth  and  enters  the  distal 
tube  from  below  (6).  The  force  of  the  spring  is  caused  by  bending 
outward  a  little  the  shorter  arm  and  inward  the  longer  arm.  When 
the  spring  is  in  action  the  short  arm  draws  outward  on  the  mesial 
surface  and  the  long  arm  forces  inward  the  disto-labial  side  of  the 
tooth,  producing  its  rotation. 

Usually  a  spur  should  be  attached  to  the  mesio-lingual  or  disto- 
lingual  surface  of  the  collar  to  project  back  of  the  adjoining  incisor,  to 
prevent  the  tooth  being  moved  out  of  the  circle.  This  device  and 
others  described  are  also  applicable  for  retaining. 

In  Fig.  320  is  shown  a  simple  appliance  for  rotating  an  incisor 
mesio-labially.  (It  is  also  used  for  the  rotation  of  two  incisors.  See 
Fig.  309.)  A  collar  is  cemented  to  the  tooth.  It  has  a  spur  on  the 
lingual  side  and  a  narrow  strip  of  plate-metal,  made  on  a  form  and 
bent  approximately  to  a  rectangular  shape,  soldered  to  the  labial  side, 
giving  an  opening  from  above  downward  and  a  little  narrower  at  the 
lower  edge.  The  opening  is  sufficiently  broad  to  admit  of  a  small 
U-shaped  loop  of  spring-wire,  the  wire  being  bent  back  on  itself,  form- 
ing a  short  curve,  with  the  depth  of  the  opening  just  the  thickness 
of  the  wire.  One  end  of  the  spring  is  left  long  and  bent  at  a  right 
angle  to  rest  on  an  adjoining  tooth.  The  required  force  is  applied 
by  bending  the  free  end  of  the  wire  backward  a  little  at  a  time, 
holding  the  looped  portion  with  flat-nosed  pliers.  Before  adjusting 
the  spring  the  loop  should  be  broadened  slightly  by  bending,  to  cause 
it  to  be  well  retained.  If  the  spring  is  to  be  left  in  position  for  a 
considerable  length  of  time,  the  side  of  the  looped  portion  of  the  arm 
can  be  notched  or  the  spring  made  secure  with  low-heat  gutta-percha 
or  other  material. 

Fig.  321  shows  an  active  device  that  is  suitable  for  the  rotation  of 
any  of  the  teeth,  and  which  has  marked  advantages  for  the  rotation 
of  the  incisors  in  special  cases.  To  the  tooth  to  be  moved  is 
cemented  a  collar  having  a  spur  on  the  lingual  side  and  a  tube  sol- 
dered on  the  labial  side  in  a  perpendicular  position,  the  tube  being 
a  little  shorter  than  the  collar.  It  is  located  near  the  mesial  or  distal 
surface  according  to  the  direction  the  tooth  is  to  be  moved,  usually 
being  placed  near  the  side  that  is  to  be  moved  outward.  A  small- 
sized  spring-wire  is  bent  into  a  long  loop,  with  one  arm  a  little 
shorter  than  the   other,  curved  upward  and  again  downward  at  a 


284 


INCISORS 


right  angle  towards  the  other  arm,  forming  a  small  narrow  loop. 
The  free  end  is  made  to  enter  tlie  tube  on  the  collar  usually  from 
above  downward  (a).  The  larger  loop  is  arranged  to  rest  on  the 
adjoining  incisor  that  is  not  to  be  moved,  with  the  long  arm  extend- 
ing below  the  line  of  the  tube  to  the  disto-labial  surface  of  the 
irregular  tooth  (6).  Force  is  caused  by  bending  forward  the  end  of 
the  shorter  arm  of  the  spring  from  time  to  time  and  adjusting  it  in 
the  tube,  which  draws  outw-ard  on  the  mesio-labial  side  of  the  incisor 
being  rotated,  while  the  long  arm  presses  inward  on  the  distal  side. 
Fig.  322  illustrates  a  similar  device.  A  collar  with  a  spur  on  the 
lingual  side  to  rest  back  of  an  adjoining  tooth  and  a  tube  located  on 

Fig.  321. 

(2  Fig.  322. 


the  mesio-labial  surface  is  cemented  to  the  incisor  to  be  moved.  A 
small-sized  spring-wire  is  bent  into  the  form  of  a  loop,  with  one  arm 
made  short  and  bent  at  a  right  angle  towards  the  other  to  enter  the 
tube,  usually  from  above  downward,  and  the  other  arm  left  long  to 
rest  on  an  adjoining  tooth,  the  width  of  the  loop  being  about  equal 
to  the  length  of  the  tube.  The  latter  is  essential  in  this  and  other 
appliances  described,  as,  w^hen  the  regulation  of  the  tooth  is  com- 
plete, the  long  arm  should  rest  next  to  the  collar  over  the  end  of  the 
tube  to  i^revent  its  removal.  Force  is  applied  by  bending  forward 
the  short  arm  of  the  spring  before  its  adjustment  in  the  tube,  and 
later  the  long  arm  can  be  bent  backward  as  desired  for  causing 
additional  force. 

It  is  an  advantage  in  some  instances,  in  the  rotation  of  a  tooth,  to 
apply  force  to  both  the  labial  and  lingual  sides.  With  this  device  a 
tube  can  be  soldered  to  the  labial  and  one  to  the  lingual  side  of  the 
collar,  each  for  the  attachment  of  a  spring.  Fig.  323  illustrates  the 
device  employed  to  rotate  a  left  lower  lateral  incisor  in  the  case  of 
Miss  C,  aged  twenty-three  years. 

Tin,'  inexperienced  will  sometimes  find  it  dilficult  to  readjust  the 
spring  in  the  tube  for  increasing  the  force,  \\\  which  case  the  end 


ROTATION   OF   INCISORS 


285 


that  enters  tlic  tube  sliould  be  left  long.     It  is  usually  best  held  with 
small,  narrow,  flat-nosed  pliers. 

Fig.   324    illustrates  a  device   that  was   used    for   the    inesio-labial 
rotation   of  a  left  upijer  lateral   incisor  in   tlie   ease  of  a  boy  aged 

Fig.  323. 

F[<;    :V2l 


fifteen  years.  A  thin  collar  with  a  tube  soldered  to  it,  a  little 
shorter  than  the  width  of  the  collar,  was  cemented  to  the  lateral. 
The  tube  was  located  perpendicularly  on  the  mesio-labial  surface, 
and  had  a  slot  cut  in  the  distal  side  next  to  the  collar,  leaving  it  in 
the  shape  of  a  hook.  A  small  spring-wire  was  bent  twice  at  right 
angles  in  the  opposite  direction,  leaving  two  arms,  one  a  little  longer 
than  the  other,  the  portion  between  the  arms  being  just  ec{ual  to 
the  length  of  the  tube.  The  spring  was  pressed  into  the  hook- 
shaped  tube,  causing  the  short  arm  to  project  on  to  the  collar  and 
the  other  on  to  the  labial  side  of  the  central  incisor.  Force  was 
applied  by  removing  the  spring  and  bending  the  ends  backward, 
four  changes  being  required  to  complete  the  regulating.  The  ap- 
paratus was  especially  convenient,  as  the  patient  was  in  attendance 
at  school  in  a  distant  town.  When  the  spring  is  to  be  left  in  posi- 
tion a  considerable  length  of  time,  oxyphosphate  of  cement  or 
shellac  should  be  applied  in  the  slot  to  prevent  its  accidental  removal. 

For  the  rotation  of  lateral  incisors  mesio-labially,  and  especially 
when  they  need  to  be  made  more  prominent,  a  device  is  shown  in 
Fig,  325.  A  collar  with  a  spur  arranged  to  project  from  the  disto- 
lingual  side  back  of  the  cuspid,  and  an  eyelet  or  very  short  tube 
located  on  the  front  near  the  mesial  surface,  is  cemented  to  each  of 
the  laterals.  A  spring  of  suitable  length  is  shaped  to  cross  the 
labial  faces  of  the  central  incisors,  with  each  end  terminating  in  a 
U-shaped  loop,  usually  projecting  upward,  one  part  of  the  loop 
resting  on  the  central  incisor  and  the  other  part  near  the  end  parallel 
with  the  eyelets  and  made  to  enter  them.  Force  is  applied  by  bend- 
ing forward  the  outer  part  of  the  loops  or  ends  of  the  spring. 

Fig.  326  illustrates  a  similar  device  with  a  long  curved  spring 


286 


INCISORS 


attached  to  the  centre  of  the  looped  spring  and  reaching  to  the 
distal  side  of  the  laterals.  Action  for  the  rotation  of  the  laterals  is 
effected  by  bending  backward  the   ends  of  the  curved  spring  and 

Fig.  325.  Fig.  326. 


bending  forward  the  ends  of  the  looped  portion  of  the  spring  that 
enters  the  tubes.  This  rotates  the  laterals  by  pressing  inward  on 
their  distal  and  outward  on  their  mesial  surfaces. 

For  the  rotation  mesio-labially  of  two  upper  incisors  with  the 
device  shown  in  Fig.  327,  a  collar  should  be  cemented  to  each  with 
a  tube  located  perpendicularly  near  the  mesial  side.  To  move  each 
tooth  a  spring  is  bent  into  a  U-shaped  loop  with  one  arm  long  and 
the  other  short,  the  distance  between  the  arms  being  equal  to  the 
length  of  the  tube.  The  short  arm  is  bent  at  a  right  angle  towards 
the  other.  The  spring  w^ould  need  to  be  inserted  in  one  of  the  tubes 
from  above  downward,  and  a  similar  spring  inserted  in  the  correspond- 
ing tube  from  below  upward,  the  springs  being  retained  by  their 
arrangement.     Force  is  caused  by  bending  outward  the  short  arms. 

For  the  mesio-labial  rotation  of  two  incisors,  a  collar  with  a  box- 
shaped  opening  can  be  cemented  to  each,  employing  a  spring  wdth 
hvo  U-shaped  loops  to  enter  the  openings  (Fig.  328).     The  part  of 


Fig.  327. 


Fig.  328. 


the  spring  between  the  loops  is  curved  upward,  forming  a  semi-  or 
complete  loop.  The  latter  is  an  advantage  when  the  teeth  are  to  be 
rotated  a  considerable  distance,  forced  farther  apart,  or  drawn  closer 
together.  The  ends  or  looped  portion  of  the  spring  are  bent  back- 
ward or  forward  according  to  the  direction  it  is  desired  to  rotate  the 
teeth.     The  appliance  will  rotate  both  of  the  teeth  either  in  one 


ROTATION  OF  INCISORS  287 

direction  or  in  op})osito  directions.  A  large-headed  pin  or  a  suitably 
shaped  metal  T  soldered  to  the  surface  of  the  collar  can  be  utilized 
in  some  instances  in  connection  with  the  looped  spring  in  place  of 
the  box-shaped  metal. 

Fig.  329  shows  an  efTective  device  for  the  rotation  of  two  incisors. 
A  collar  with  a  short  tube  or  eyelet  is  cemented  to  each  tooth,  the 

Fig.  329.  Fig.  330. 


tube  being  placed  horizontally  near  the  mesio-labial  surface.  Through 
the  sides  of  each  tube  near  the  mesial  end  a  small  hole  is  drilled  for 
the  passage  of  the  ends  of  a  spring.  The  spring  is  shaped  to  cross 
in  front  of  the  incisors,  usually  close  above  the  tubes,  with  the  ends 
curved  downward  and  towards  the  mesial  surface  of  the  teeth  below 
the  tubes,  where  they  are  bent  at  a  right  angle  to  pass  upward  through 
the  openings  provided  for  them.  Pressure  is  applied  by  bending 
the  free  ends  of  the  spring  forward  a  little  and  forcing  them  into  the 
openings.  The  spring  can  be  arranged  to  have  the  ends  pass  through 
the  tubes  from  above  or  below  as  desired. 

Another  form  of  device  for  double  rotation  that  is  easily  constructed 
is  shown  in  Fig.  330.  A  collar,  with  a  strip  of  metal  of  nearly  equal 
width,  bent  into  the  form  of  a  flange  or  hook,  soldered  to  the  mesio- 
labial  surface  of  the  collar,  is  cemented  to  each  of  the  teeth  to  be 
rotated ;  the  flanges  being  made  to  project  from  either  way,  usually 
towards  the  median  line.  A  spring  is  bent  into  a  U-shaped  loop  with 
the  sides  parallel,  and  with  the  distance  between  them  just  sufficient 
to  pass  underneath  the  hook-shaped  flanges  on  the  collars  when  in 
position.  The  ends  of  the  spring  below  the  flanges  are  bent  out- 
ward to  rest  on  the  collars.  The  spring  is  inserted  from  below 
upward.     To  increase  the  force  the  ends  are  bent  backward. 

The  mesio-labial  rotation  of  two  incisors,  with  a  spring  on  the 
lingual  side,  is  shown  in  Fig.  331. 

A  collar  with  a  tube  attached  near  the  gum  is  cemented  to  each 
of  the  teeth  to  be  rotated.  A  section  is  removed  from  the  side  of 
one  of  the  tubes  close  to  the  collar,  leaving  the  balance  of  it  in  the 


288 


INCISORS 


form  of  a  hook.  A  straight  wire  is  then  passed  into  the  tube  on  the 
opposite  collar,  and  tlie  end  sprung-  into  the  hook.     The  tendency  of 

the  wire  to  straighten  rotates 
the  teeth  outward,  and  when 
the  wire  has  become  straight  it 
can  be  utilized  for  rotating  the 
teeth  fartlier  in  the  same  direc- 
tion, by  soldering  to  it  opposite 
the  median  line  a  sliort  narrow 
piece  of  plate-metal  to  prevent 
the  wire  from  turning  in  the 
tubes,  when  the  ends  may  be 
bent  to  move  the  teeth  as  far 
as  necessary.  If  the  end  of  the 
spring  is  not  well  retained  in  the  hook  on  the  collar,  it  is  advisable 
to  close  the  slot  with  a  small  amount  of  oxyphosphate. 

Fig.  332  shows  a  similar  device  having  a  long  spring  for  rotating 
the  upper  incisors. 

A  spring-wire  is  formed  into  a  U-shaped  loop  pointing  back- 
ward at  the  median  line  towards  the  roof  of  the  mouth,  with  the 
ends  bent  outward,  one  of 
them  extending  through  a 
tube  attached  to  tlie  lingual 
side  of  a  collar  on  the  left  in- 
cisor, and  the  other  held  Avith 
a  hook  on  the  lingual  side  of 
the  right  incisor.  The  wire 
bent  in  the  form  of  a  loop  in 
this  manner  has  the  advantage 
of  being  more  springy;  it  is 
easily  manipulated,  and  does 
not  require  to  be  changed  as 

often  as  some  other  forms,  its  shape  preventing  the  spring  from  twist- 
ing in  the  tubes.  The  ends  of  the  spring  can  be  bent  backward  to 
rotate  the  teeth  as  far  as  required. 

Fig.  333  illustrates  a  device  for  the  rotation  of  two  incisors,  or 
an  incisor  and  a  lateral,  both  in  the  same  direction.  A  collar  is 
cemented  to  each  of  tlie  teeth  to  bo  moved,  having  an  eyelet  or  a 
very  short  tube  arranged  perpendicularly  on  the  collar,  or  a  tube 


Fig.  332. 


ROTATION   OF  INCISORS 


289 


Fig.  33r,. 


arranged  horizontally  with  a  hole  in  the  side,  as  shown  in  Fig.  307, 
the  tube  or  eyelet  being  located  near  the  side  of  the  tooth  that  is  to 
be  moved  outward. 

A  spring  is  shaped  to  rest  on  the 
prominent  i)art  of  one  tooth  and  ex- 
tend to  the  prominent  part  of  the 
other,  passing  below  the  line  of  the 
tubes.  The  ends  of  the  spring  are 
shaped  to  curve  upward  and  cross 
the  widtli  of  the  teeth  above  the  line  of  the  tubes,  where  they  are 
bent  downward  at  a  right  angle  to  enter  the  tubes  or  eyelets.  Force 
for  the  rotation  is  produced  by  bending  the  ends  of  the  spring  out- 
ward a  little  before  each  adjustment. 

Fig.  334   illustrates  the  case  of  a  boy  aged  ten  years,  with  the 
mesial  surface  of  the  upper  central  incisors  twisted  inward. 

A  conical  shaped  supernumerary  tooth  was  erupted  between  the 
incisors  and  had  been  extracted.     The  left  incisor  crossed  the  arch 
Pjq  334  at  nearly  a  right  angle,  and  the 

right  incisor  was  twisted  still 
farther,  the  lingual  surface 
resting  in  contact  with  an 
erupting  lateral.  An  appli- 
ance for  their  mesio  -  labial 
rotation,  which  moved  them 
to  position  without  any  ap- 
parent congestion,  was  con- 
structed similar  to  the  one 
shown  in  the  figure.  It  was 
made  by  first  cementing  to 
each  of  the  incisors  a  gold  collar  with  a  tube  on  the  lingual  side,  and 
anchoring  a  lingual  base-wire  by  spring-clasp  attachments  to  the 
second  deciduous  molars,  the  base-wire  following  close  to  the  side 
of  the  teeth.  A  small  spring  was  formed  to  extend  into  the  tube 
on  the  left  incisor  from  the  mesial  side;  it  was  bent  backward, 
following  the  left  curve  of  the  arch,  and  terminated  in  a  hook, 
shaped  to  pass  around  the  base-wire  from  the  lingual  side  near  the 
anchorage.  Force  was  applied  by  removing  the  spring  and  bending 
backward  the  end  near  where  it  entered  the  tube,  and  hooking  the 
other  end  in  place  over  the  base-wire, 

19 


290 


INCISORS 


The  right  incisor  was  rotated  in  a  similar  manner.  The  spring- 
entered  the  tube  from  the  mesial  end,  and  was  attached  to  the  base- 
wire  on  the  right  side  with  a  hook,  but  a  U-shaped  loop  was  formed 
in  the  wire  opposite  the  right  cuspid  for  the  purpose  of  lengthening 
it  and  making  it  more  springy,  the  loop  being  opened  to  meet  the 
requirements.  After  the  teeth  were  rotated  to  proper  positions 
they  were  retained  by  cementing  to  them  two  gold  collars  united 
with  solder. 

When  the  shaping  of  the  end  of  a  spring  into  a  hook  for  attach- 
ment to  the  base-wire  in  the  manner  described  proves  difficult, 
small  wire  hooks  may  be  soldered  to  the  base-wire  in  form  to  hold 
the  ends  of  the  springs;  or  two  small  springs  may  be  directly 
soldered  to  the  base-wire  for  the  rotation  of  each  tooth,  one  shaped 
to  bear  on  the  linguo-mesial  and  the  other  on  the  labio-distal  side. 

Fig.  335  shows  a  method  of  rotating  the  teeth  with  springs  in 
connection  with  a  palatine  plate  when  considerable  force  is  required. 

Fig.  335. 


A  collar  with  a  tube  on  the  lingual  side  is  cemented  to  each  of  the 
teeth  to  be  moved,  and  a  metal  hook  arranged  in  the  plate  in  suit- 
able position,  usually  near  the  bicuspids  or  molars,  to  hold  the  end 
of  a  spring  that  is  shaped  to  enter  the  tube  on  the  collar.  The 
figure  illustrates  the  arrangement  for  rotating  a  right  central  and  a 
left  lateral  incisor. 

When  force  is  a}>plied  to  a  spring  in  rotating,  it  is  liable,  if  not 
counteracted,  to  move  the  tooth  out  of  the  circle  in  the  direction  of 
the  force,  often  causing  tlie  tooth  to  assume  a  false  position.  This 
is  usually  prevented  by  extending  a  spur  from  the  collar  to  rest  on 


ROTATION  OF  INCISORS 


291 


an  adjoining  tooth.  Witli  Ihc  form  of  apparatus  described  the  plate 
prevents  the  tooth  from  being  pressed  too  far  into  the  circle,  and 
forms  an  anchoraj^-e  for  the  free  end  of  the  spring.  When  desired  the 
spring  may  be  bent  at  a  right  angle  just  back  of  tin;  hook  on  the  plate 
for  causing  the  tension  required  to  draw  the  tooth  into  the  circle. 

Fig.  336  illustrates  a  case  in  which  an  unsuccessful  attempt  had 
been  made  by  a  general  practitioner  to  correct  the  position  of  the 
incisors,  including  the  rotation  of  the  laterals. 

When  the  case  was  presented,  the  upper  central  incisors  were  not 
prominent  enougli  to  close  in  front  of  the  lower  incisors.  I  first 
moved    them    outward   by 


Fig.  336. 


means  of  a  spring  passing 
under  lugs  soldered  on  the 


lingual  side  of  collars  that 
were  cemented  to  them. 
When  they  were  moved 
outward  to  proper  position, 
which  also  gave  the  neces- 
sary space  for  the  laterals, 
they  were  retained  by  a  vul- 
canite palatine  plate.  To 
this,  on  either  side,  was 
attached  a  wire  arm  ex- 
tending over  the  arch  at  the  junction  of  the  bicuspids,  with  the 
end  bent  in  the  form  of  a  hook  resting  near  the  gum  on  the  buccal 
side.  A  collar  with  a  tube  on  the  labial  side  Avas  cemented  to  each 
of  the  lateral  incisors.  Spring-wires  were  shaped  to  extend  into 
the  tubes  and  the  ends  sprung  backward  to  pass  through  the  hook- 
shaped  arms.  This  arrangement  gave  the  unusual  force  required 
for  rotating  each  of  the  lateral  incisors  with  a  single  spring,  without 
losing  their  position  in  the  circle  of  the  arch.  When  the  laterals 
had  been  moved  to  place,  they  were  retained  by  cementing  to  them 
collars  with  spurs  shaped  to  extend  on  to  the  lingual  side  of  the 
cuspids  and  the  labial  side  of  the  central  incisors.  The  plate  was 
worn  for  a  time  to  preserve  the  circle  of  the  arch. 

The  principles  involved  in  the  rotation  of  the  incisors,  and  nearly 
all  of  the  methods  that  have  been  described  in  this  chapter,  are 
equally  applicable  for  the  rotation  of  the  cuspids  and  bicuspids,  and 
for  retaining  teeth  after  their  regulation. 


CHAPTER   XV 

INCISORS,    TO    DEPRESS— SHAPING    THE    TEETH 

Teeth  that  do  not  articulate  with  those  of  tlie  opposite  arch  and 
teeth  affected  with  pyorrhoea  alveolaris  are  gradually  extruded  from 
their  sockets,  lengthening  theni  in  appearance.  The  teeth  that  are 
most  often  affected  are  the  upper  and  lower  incisors  and  cuspids  ;  less 
often  the  bicuspids  and  molars  that  have  no  occlusion.  The  latter 
may  result  from  the  extraction  of  the  antagonizing  teeth.  Sometimes 
teeth  used  for  anchorage  are  raised  in  their  sockets  by  the  pressure 
of  an  appliance.  After  its  removal  they  generally  settle  back  again, 
but  it  usually  requires  the  application  of  a  considerable  force  to  de- 
press teeth  that  have  become  extruded  from  natural  causes.  When 
the  molars  and  bicuspids  have  become  elevated  from  general  lack  of 
occlusion  (Figs.  99,  108,  and  111),  the  correction  of  their  position  is 
usually  sufficient,  the  new  occlusion  with  the  antagonizing  teeth 
causing  them  to  settle  back  in  their  sockets. 

Extrusion  of  the  incisors  is  most  apparent  when  they  have  erupted 
too  prominently.  There  being  no  occlusion  to  prevent,  they  gradu- 
ally become  elevated,  requiring  their  depression  in  the  process  of 
regulating.  Not  uncommonly  the  lower  incisors  impinge  against  the 
necks  of  the  upper  incisors  or  the  gum  tissue  back  of  them,  necessi- 
tating their  depression  or  being  dressed  away  to  shorten  them  before 
moving  backward  those  of  the  upper  arch  (Fig.  275).  Wiien  the 
lower  incisors  close  in  front  of  the  upper  ones  they  also  may  become 
extruded  to  such  an  extent  as  to  impinge  against  the  gum  (Fig.  184). 
The  dressing  or  shaping  of  incisors  is  only  recommended  when 
their  depression  is  not  practicable  and  for  patients  of  a  mature  age. 

An  appliance  for  depressing  lower  incisors  is  shown  in  Fig.  337. 
It  consists  of  a  vulcanite  palatine  plate  anchored  with  a  suction, 
wire-clasps,  or  spring-clasps.  The  anterior  portion  of  the  plate  is 
thickened  so  that  in  closing  the  jaws  all  of  the  pressure  in  occlusion 
is  caused  on  the  lower  incisors,  and  sometimes  including  the  cuspids. 
The  f:ontinued  and  constant  application  of  pressure  in  this  manner 
gradually  forces  these  tcf.'th  more  deeply  into  their  sockets.  When 
the  })osition  of  tin,"  lovv(,-r  incisors  is  not  to  be  changed  otherwise, 

292 


DEPRESSION  OF  INCISORS  293 

slight  indentations  should  be  made  for  them  in  the  rubber,  but  when 
they  need  to  be  moved  outward  it  can  be  done  at  the  same  time  they 
are  being  depressed  by  shaping  the  thickened  portion  of  the  plate 
described  to  slope  forward  in  the  form  of  an  inclined  plane.     This 


means  of  depressing  the  incisors  should  generally  be  employed  before 
the  age  of  twenty-one,  although  it  has  been  used  successfully  for  pa- 
tients of  a  more  mature  age.  As  the  teeth  are  liable  to  return  to 
their  former  position  they  should  be  depressed  more  than  it  is 
intended  they  shall  remain. 

It  is  usually  necessary  to  face  the  incline  with  sheet-metal,  as  vul- 
canite is  not  sufficiently  hard  to  resist  the  continued  force  of  the 
lower  teeth  without  wearing  away  the  plate,  which  would  interfere 
with  their  outward  movement.  The  metal  can  be  attached  when  the 
plate  is  being  made,  or  riveted  to  the  plate  with  large  pins  at  a  later 
time.  Additional  layers  of  metal  can  be  attached  as  required  with  soft 
solder,  using  a  soldering  iron,  first  tinning  the  surface  of  the  metal. 

When  at  the  same  time  upper  incisors  are  to  be  moved  inward, 
there  being  spaces,  a  similar  plate  with  a  semicircular  spring  extend- 
ing around  the  front  of  the  arch,  as  illustrated  in  Fig.  338,  can  be 
employed,  or  finger-springs,  as  shown  in  Fig.  242.  As  the  upper 
incisors  are  moved  inward  with  the  spring,  the  anterior  edge  of  the 
plate  should  be  dressed  away  a  little  as  required  to  permit  their 
movement.  For  retaining,  the  same  plate  should  be  worn  for  several 
months  after  the  teeth  are  in  position. 


294  INCISORS 

The  lingual  surface  of  the  upper  incisors  forms  a  curved  incline 
reaching  from  near  the  cingulum  to  the  morsal  margin,  and  when 
the  teeth  are  forced  inward  nearly  in  contact  with  the  lower  in- 
cisors, if  it  is  found  that  the  upper  incisors  need  to  be  depressed, 

Fig.  338. 


the  pressure  with  the  springs  should  be  continued,  driving  their 
inclined  surfaces  against  the  edge  of  the  plate.  This  will  force  them 
more  deeply  into  their  sockets.  If  any  further  shortening  of  the 
upper  incisors  is  required,  a  collar  with  a  lug  on  the  labial  side 
(Fig.  339,  a)  can  be  cemented  to  each  of  the  teeth  to  be  moved,  hav- 
ing the  lugs  in  position  so  that  the  spring  (6),  passing  in  front  of  the 
teeth,  will  rest  below  the  lugs  and  cause  an  upward  pressure  on 
them. 

When  it  is  necessary  to  elevate  the  incisors  the  spring  should  be 
arranged  to  rest  above  the  lug,  causing  downward  pressure. 

In  Fig.  340  is  shown  a  simple  device  for  depressing  the  upper  in- 
cisors, made  by  bending  a  narrow  piece  of  plate-metal  into  an  S-shapc, 
with  one  end  (c)  formed  to  hook  over  the  edge  of  one  or  two  of 
the  incisors,  and  the  other  end  to  hook  over  the  spring  (b).  The 
metal  can  be  soldered  to  the  spring  when  desired.  Lower  incisors 
can  be  depressed  in  a  similar  manner. 

Several  years  since  a  method  was  devised  of  depressing  both  the 
upper  and  lower  incisors  at  oiio  time  (Fig.  341),  by  cementing  to 
each  of  the  upper  incisors  to  be  acted  upon  a  thin  gold  collar,  with  a 


DEPRESSION  OF  INCISORS 


295 


piece  of  plate-metal  shaped  in  the  form  of  a  shallow  trough  soldered 
to  the  lingual  side  (d),  into  whicli  the  lower  incisors  thrust  as  the 
teeth  come  together. 

When  the  upper  incisors  are  in  good  lino  it  is  sometimes  preferable 
to  cement  to  them  a  metal  cap  struck  up  with  dies  and  having  a 
properly  shaped  trough  soldered  on  the  lingual  side.  Fig.  378  illus- 
trates a  similar  cap,  with  arms  projecting  backward  from  it  on  each 
side  of  tlie  arch  to  rest  on  the  grinding  surface  of  the  molars,  that 
was  used  to  depress  the  incisors,  and  at  the  same  time  to  sustain 
the  position  of  the  upper  incisors  as  they  were  being  moved  bodily 
inward. 

When  both  the  upper  and  lower  incisors  are  extruded,  with  the 
lower  incisors  in  good  line  and  upper  ones  too  prominent,  an  ap- 
paratus for  their  correction  can  be  made  for  the  upper  arch  by 
arranging  a  heavy  lingual  base-wire  far  enough  back  of  the  incisors 
to  permit  the  lower  ones  to  rest  in  front  of  it  in  occlusion,  and  an- 
chored with  partial-clasps  and  spring-clasp  attachments.  To  the 
base-wire  (Fig.  342,  e)  is  soldered  plate-metal,  shaped  in  the  form  of  a 


Fig.  341. 


Fig.  342. 


Fig.  339. 


Fig.  340. 


cap  or  inclined  plane,  sloping  forward  and  downward,  fitting  the 
lingual  side  of  the  upper  incisors  near  the  gum.  Strips  of  plate- 
metal  are  attached  to  the  cap  and  project  from  it,  with  the  ends  bent 
up  in  the  form  of  hooks  to  pass  over  the  edge  of  the  upper  incisors, 
extending  about  one-third  or  one-half  the  length  of  their  crowns 
to  rest  on  the  labial  side,  as  seen  at  /,  as  further  illustrated  in  the 
following  cut.  The  apparatus  is  so  adjusted  that  when  the  teeth 
strike  in  occlusion  force  is  applied  both  to  the  upper  and  lower 
incisors,  driving  them  into  their  sockets.     The  pressure  is  increased 


296 


INCISORS 


by  curving  the  strips  of  metal  upward  and  backward  towards  the 
base-wire  from  time  to  time  ;  this  gradually  depresses  the  incisors, 
at  the  same  time  moving  the  upper  ones  inward.  The  lower 
incisors  are  held  in  an  upright  position  by  their  occlusion  in  front  of 
the  base-wire. 

When  both  the  upper  and  lower  incisors  are  too  prominent  and 
need  to  be  moved  inward  and  at  the  same  time  forced  into  their 

sockets,  a  similar  apparatus 
^^°'  ^^^-  with   strips    of  plate-metal 

attached  to  a  lingual  spring 
base- wire  can  be  employed 
(Fig.  343).  The  wire  should 
have  U-shaped  loops  in  it, 
one  arranged  on  either  side 
of  the  arch  opposite  the 
cuspid  or  first  bicuspid. 
The  gradual  closure  of 
the  loops  causes  traction, 
forcing  inward  the  upper 
incisors,  while  the  down- 
ward slope  of  the  metal  acts  like  an  inclined  plane,  gradually  forcing 
the  lower  incisors  inward  and  downward. 

For  depressing  the  upper  incisors  and  moving  them  inward,  where 
more  pressure  is  required,  occasionally  it  is  advisable  to  apply  exter- 
nal force  with  a  cross-bar  (Fig.  69). 

An  apparatus  that  has  been  used  to  good  advantage, 
generally  in  connection  with  other  apparatus,  for  de- 
pressing upper  and  lower  incisors  in  cases  of  double 
protrusion,  and  at  the  same  time  moving  them  in- 
ward, is  illustrated  in  Fig.  344.  A  metal  cap  with  a 
lingual  flange  ((/)  is  fitted  to  the  upper  incisors ;  the 
lower  incisors  rest  against  the  flange  in  occlusion. 
A  socket  on  the  labial  side  (Ji)  is  sonjetimes  provided 
for  the  application  of  supplemental  force  witli  a  cross- 
bar. 

When  desirable,  the  cap  is  cemented  to  the  teeth,  especially  when 
used  for  retaining  (Figs.  508  and  509). 

Teeth  that  have  been  moved  by  any  of  the  methods  described 
should  be  retained  for  a  considerable  length  of  time. 


Fig.  344. 


Fig.  345. 


SHAPING  mCISORS  AND  OTHER  TEETH  297 

Dr.  Goddard  has  described  a  method  of  depressing  the  lower 
incisors  with  external  anchorage  as  follows  :*  "  A  metal-cap  is 
swaged  to  fit  over  the  occlusal  edges.  To  this  is  soldered  a  wire 
that  extends  out  of  the  corners  of  the  mouth  and  is  bent  into  hooks 
one  at  each  end.  From  these  hooks  rubber  bands  extend  to  a 
chin-piece.  To  prevent  this  chin-piece  from  sliding  forward  it  is 
necessary  to  extend  a  tape  from  it  around  the  patient's  neck." 

Fig.  345  illustrates  a  method  I  devised  for  depressing  the  lower 
incisors.  A  chin-cap  and  wire  standards  are  supported  by  a  cranial- 
cap.  A  depressing  bar  (Fig.  346)  is  made  on  a  model  by  fitting  a  nar- 
row strip  of  plate-metal  over  each  of  the  teeth  to  be  moved.    Across 

Fig.  346. 


the  front  of  them  is  soldered  a  wire  shaped  to  the  arch,  its  ends  pro- 
jecting over  the  lower  lip  at  the  corners  of  the  mouth  and  bent 
backward,  where  a  small  metal  knob  is  soldered.  Pressure  on  the 
teeth  is  produced  by  hooking  elastic  bands  over  the  knobs  and  to 
knobs  on  the  lower  part  of  the  chin-cap.  The  latter  are  adjustable, 
being  moved  backward  or  forward  on  the  standard  and  screwed  to 
place  to  change  the  line  of  traction. 

When  a  thickened  plate  (Fig.  837)  is  used  for  depressing  the  lower 
teeth,  the  operation  is  hastened  by  upward  pressure  with  a  chin-cap. 

Shaping  the  Teeth. — The  operation  of  depressing  teeth  in  their 
alveoli  is  frequently  a  prolonged  one,  and  it  is  necessary  that  they 
be  retained  a  considerable  length  of  time.  When  this  procedure 
is  not  considered  judicious,  dressing  of  the  teeth  may  be  employed 
to  improve  the  contour  of  those  that  have  become  extruded.  Dress- 
ing is  also  employed  for  evening-up  teeth  to  improve  the  occlu- 
sion, for  improving  the  surface  and  contour  of  those  affected  with 
abrasion,  to  level,  making  smooth  the  surfaces  of  those  that  have 
been  fractured,  and  to  dress  away  the  uneven  surfaces  of  teeth  after 
regulation  for  improving  their  appearance  and  occlusion.  When  teeth 
have  become  extruded  from  natural   causes,  as  from  lack  of  occlu- 

*  Goddard,  American  Text-Book  of  Operative  Dentistry,  1897,  p.  643. 


298 


INCISORS 


sion,  from  calcareous  deposits  about  their  roots  or  pyorrhoea  alveo- 
laris,  or  from  the  lateral  crowding  of  teeth  from  peculiar  occlusion, 
it  is  generally  better  to  dress  their  surfaces  rather  than  to  depress 
them  in  the  alveoli. 

The  two  following  cases,  one  of  extrusion  and  the  other  of  abra- 
sion, were  described  and  illustrated  by  Dr.  How.*     Fig.  347  shows 


Fig.  347. 


Fig.  348. 


an  elongated  condition  of  the  upper  incisors,  which  was  improved 
by  dressing  away  their  surfaces,  as  seen  in  Fig.  348,  thus  attaining  a 
pleasing  appearance  without  material  detriment  to  the  teeth.  This 
is  best  done  with  a  corundum  stone  or  file,  after  which  they  should 
be  thoroughly  polished.  Fig.  349  represents  a  case  where  the 
lower  incisors  had  become  abraded,  leaving  them  jagged,  with  some 


Fig.  349. 


Fig.  350. 


of  the  teeth  much  longer  than  others.  Fig.  350  illustrates  the  result 
after  the  teeth  were  shaped  by  dressing. 

Cases  of  abrasion  are  common,  often  affecting  the  cuspids,  bicus- 
pids, and  molars,  as  well  as  the  incisors.  When  the  enamel  is  worn 
away  the  dentine,  being  less  dense,  wears  more  rapidly  and  becomes 
hollowed  out,  leaving  tlie  sharp  edge  of  the  enamel  projecting. 
Fillings  should  be  inserted  in  these  depressions,  or  the  projecting 
surfaces  dressed  smooth  and  polished  to  stay  the  progress  of  attri- 
tion, otherwise  the  roughened  edges  would  continue  to  gouge  away 
the  enamel  and  dentine  of  the  antagonizing  teeth. 

When  the  incisors  are  crowded,  rotated,  or  overlap  one  another, 
requiring  slight  additional  space   for  their  correction,  it   can  some 


*  How,  Dental  Cosmos,  1886,  p.  741. 


SHAPING  INCISORS  AND  OTHER  TEETH  299 

times  be  gained  by  dressing  the  approxinial  surfaces  of  the  teeth 
slightly,  tlius  relieving  the  necessity  of  extraction  or  the  expansion 
of  the  arch,  but  never  dressing  to  the  extent  of  removing  all  of  the 
enamel  from  any  part.  The  ^vriter  usually  favors  the  dressing  of  the 
approxinial  surfaces  of  the  bicuspids  and  molars  when  sufficient 
space  can  be  gained  in  that  manner.  The  proper  shaping  of  ap- 
proxinial surfaces  that  have  been  crowded  and  rotated  often  gives  a 
suitable  bearing  for  retaining  the  teetli  in  an  harmonious  position 
(Fig.  514). 

A  gratifying  result  lias  been  obtained  by  grooving  longitudinally 
the  approxinial  surfaces  of  a  crowded,  irregular  lower  incisor,  and 
rounding  the  crowns  of  the  adjoining  ones  sufficiently  to  fit  into  the 
grooves,  which  supported  the  tooth  and  prolonged  its  usefulness  for 
several  years. 

Dressing  the  surfaces  of  the  teeth  is  called  for  in  some  instances, 
to  improve  the  occlusion  after  their  regulation,  as  resliaping  the 
cusps  of  the  bicuspids  and  molars,  making  them  fit  better  into  the 
sulci  of  the  teeth  or  the  interproximate  spaces  of  the  opposite  arcli. 
The  writer  has  resorted  to  this  practice  for  adults  after  jumping  the 
bite,  thus  establishing  a  new  occlusion.  The  value  of  the  operation 
has  been  proved  by  the  permanence  of  tlie  improvement  after  many 
years. 

Teeth  that  have  become  extruded  in  the  process  of  regulation 
should  not  be  dressed  away  until  after  an  interval  of  time,  permitting 
them  to  settle  into  their  sockets. 


CHAPTER  XVI 


INCISORS,   TO  ELEVATE 

This  chapter  will  describe  the  construction  of  apparatus  for 
causing  tlie  elevation  of  incisors  in  cases  of  improper  or  tardy  de- 
velopment ;  of  teeth  retained  by  impaction  ;  and  for  the  elevation 
of  incisors  that  have  lost  part  of  their  crowns  from  accidental 
fracture. 

Fig.  351  illustrates  an  appliance  arranged  for  the  elevation  of  an 
upper  incisor.  A  broad  collar  with  two  tubes  soldered  perpendicu- 
larly on  the  labial  side  is  cemented  to  the  tooth  to  be  elevated.  The 
ends  of  the  tubes  are  far  enough  from  the  gum  to  permit  the  insertion 
in  each  of  a  small-sized  spring-wire,  which  is  bent  at  a  right  angle  to 


Fig.  351. 


Fig.  352. 


enter  the  tube.  The  free  end  of  each  of  the  wires  is  curved  down- 
ward and  shaped  to  hook  a  little  over  the  grinding  surface  of  one  or 
more  of  the  adjoining  teeth.  Force  is  applied  by  changing  the  curve 
of  the  springs. 

In  place  of  the  perpendicular  tubes,  a  box-shaped  attachment  can 
be  made  to  the  collar  (Fig.  352)  for  the  admission  of  a  U-shaped 
loojj  of  si>ring-wire,  with  projecting  arms  entering  from  above  down- 
ward, made  as  described  in  connection  with  Fig.  309.  The  ends  of 
the  arms  of  the  spring  are  shaped  to  catch  over  the  grinding  sur- 
face of  two  or  more  of  the  adjoining  teeth.  When  there  is  but  a 
slight  difference  in  the  apparent  length  of  the  teeth,  they  can  be 
brougiit  to  the  same  level  with  a  device  as  described  in  connection 
with  Fig.  306  or  308. 

Fig.  353  illustrates  a  simple  device  for  elevating  a  retarded 
incisor.     It  is  made  by  lltting  two  small  saddles  in  the  form  of  caps 

800 


ELEVATION  OF  INCISORS 


301 


Fig.  353. 


to  pass  over  two  or  more  teeth  on  either  side  of  the  incisor  to  be 
elevated,  the  caps  being  of  very  thin  metal,  as  ])latininn.  They  are 
shaped  to  the  te(;th  by  pressing  tlio  metal  over  th(;m  with  a  piece  of 
hard  rubber,  with  the  assistance  of  the  patient  biting  upon  it ;  or 
the  nietal  can  be  swaged.  A  small 
spring-wire  is  shaped  to  cross  the 
labial  side  of  tlie  teeth,  then  bent  at 
right  angles  with  the  ends  curved  to 
hook  over  the  saddles  at  the  junction 
of  the  teeth.  The  ends  of  the  spring 
should  be  attached  to  the  lingual  side  of  the  saddles  with  solder, 
using  enough  to  stiffen  the  metal  of  the  caps,  but  it  should  not  be 
attached  to  the  labial  side,  as  it  w'ould  interfere  with  its  springiness. 
A  collar  with  a  short  pin  soldered  to  the  labial  side  is  cemented  to 
the  tooth  to  be  moved.  Force  is  applied  by  adjusting  the  apparatus 
and  springing  the  bar  over  the  pin,  bending  downward  the  central 
portion  of  the  bar  from  time  to  time  as  additional  pressure  is  re- 
quired. 

When  the  force  is  not  sufficient,  a  similar  bar  can  be  made  to 
extend  on   the  lingual  side  of  the  teeth,  suspended  from  the   sad- 
dles, and  made  to  extend  below  a  lug  similar  to  the  one  described. 
If  the  tooth  to  be  moved  is  wedged  betw^een  the  adjoining  ones, 
Pjg  35^  the  space  can  be  increased  by 

straightening  the  curves  of  the 
spring  near  the  attachment 
to  the  saddles,  lengthening  it 
slightly. 

A  removable  device  with  a 
finger-spring  for  elevating  teeth 
of  the  upper  or  lower  arch  is 
made  by  anchoring  a  lingual 
base-wire  with  spring-clasp  at- 
tachments, having  plate-metal 
shaped  to  hook  over  several 
of  the  teeth  on  either  side  of  the  tooth  to  be  elevated  (Fig.  354). 
It  is  to  be  soldered  to  the  base- wire  on  the  lingual  side.  A  finger- 
spring  is  made  to  extend  from  the  base-wire  over  the  arch  at  the 
junction  of  two  of  the  teeth  and  extend  forward,  passing  under  a 
lug  on  a  collar  cemented  to  the  tooth  to  be  moved.     When  used  in 


302  INCISORS 

the  lower  arch,  the  necessary  force  is  supphed  by  bending  upward 
the  spring  sHghtly  from  time  to  time. 

If  two  or  more  teeth  are  to  be  elevated,  or  if  more  force  is  re- 
quired, an  additional  fmger-spring  can  be  attached  in  a  similar  man- 
ner to  the  base-wire  on  the  opposite  side  of  the  arch,  or  the  spring 
can  be  made  continuous,  each  end  extending  over  the  arch  and 
soldered  to  the  base-wire.  This  apparatus  does  not  interfere  with 
the  occlusion ;  the  spring  is  readily  controlled,  graduating  the  force, 
and  is  easily  removed  for  cleansing. 

Fig.  355  illustrates  an  appliance  that  was  used  for  the  elevation 
of  a  right  upper  central   incisor  that  had   been  fractured.      Both 

Fig.  .355. 


upper  lateral  incisors  had  erupted  in  a  twisted  position.  They  were 
rotated  mesio-lingually  by  means  of  a  device  as  seen  in  Figs.  312  and 
313,  there  having  been  a  collar  with  a  tube  on  the  lingual  side  ce- 
mented to  each  of  the  laterals  to  accommodate  the  device  for  rotating, 
after  which  a  slightly  curved  wire  was  passed  through  the  tubes  for 
retaining,  as  seen  in  the  figure.  About  one-third  of  the  crown  of 
the  right  upper  incisor  was  lost  by  an  accident.  The  appliance  for 
its  elevation  was  made  by  forming  a  lingual  base- wire  to  pass  just 
back  of  the  tubes  and  wire  on  the  lingual  side  used  for  retaining, 
with  the  ends  extending  backward  to  be  soldered  to  a  spring-clasp 
attafhmcnt  for  anchorage  over  each  of  the  second  bicuspids.  The 
right  deciduous  cuspid  was  absent  and  the  permanent  one  had  not 
yet  appeared.  A  spring-wire  was  soldered  to  the  base-wire  on  the 
right,  and  passed  outward  to  the  labial  side  through  this  space; 
there  it  was  bent  forward  and  shaped  to  rest  in  a  hook  on  a  collar 


ELEVATION  OF  INCISORS  303 

that  was  cemented  to  the  incisor  to  be  elevated.  The  front  part 
of  tlie  appliance  was  supported  and  prevented  from  pressing  against 
the  gum  by  soldering  pieces  of  plate-metal  to  the  base-wire  on  eitlier 
side,  having  them  curved  in  shape  to  hook  over  and  rest  on  the 
tubes  on  the  collars  cemented  to  the  laterals.  Force  for  elevating 
the  tooth  was  caused  by  bending  downward  the  end  of  the  spring. 

In  Fig.  356  is  illustrated  a  device  recommended  by  Dr.  Goddard  for 
the  elevation  of  a  fractured  incisor,  the  object  being  to  elevate  the 

Fig.  356. 


incisor,  then  to  dress  the  edge  sufficiently  to  bring  it  into  harmony 
with  the  adjoining  teeth.*  The  apparatus  is  made  by  fitting  to  a 
tooth  on  either  side  of  the  one  to  be  moved  a  cap  having  a  stiff 
bar  of  metal  shaped  to  connect  the  two,  and  curved  downward  in 
the  centre  to  pass  below  the  tooth  to  be  moved.  A  collar  having 
a  spur  on  the  labial  side  and  another  on  the  lingual  side  is  cemented 
to  the  incisor,  and  the  necessary  force  is  got  by  stretching  a  rubber 
ligature  over  the  bar  and  hooking  it  to  the  spurs  on  the  collar. 

The  gradual  elevation  of  a  tooth  usually  drags  the  gum  and  the 
process  with  it,  and  accordingly,  when  the  edge  is  dressed  away  in 
the  manner  described,  it  causes  a  shortening  of  the  crown  as  com- 
pared with  the  adjoining  ones.  Teeth  moved  in  this  manner  should 
be  retained  a  long  time,  as  invariably  there  is  a  tendency  for  the 
process  and  tooth  to  return  to  their  original  position.  Separating 
the  gum  from  the  neck  of  the  tooth  from  time  to  time  during  the 
regulation  causes  the  gum  to  recede,  and  results  in  an  apparent 
lengthening  of  the  crown.  Another  complication  is  the  overlap  of 
the  bite.  As  the  upper  incisor  is  forced  downward,  the  occlusion 
with  tlie  lower  incisors  causes  it  to  become  too  prominent.     This 

*  Goddard,  American  Text-Book  of  Operative  Dentistry,  1897,  p.  595. 


304  INCISORS 

can  be  overcome  only  by  grinding  the  lingual  face  of  the  upper 
incisor  enough  to  cause  a  proper  occlusion,  or  by  forcing  the  lower 
incisors  inward  or  downward.  The  latter  procedure  I  do  not  re- 
gard with  favor. 

The  elevation  of  cuspids,  bicuspids,  and  molars  is  effected  by 
similar  apparatus.  (For  further  reference,  see  their  respective 
chapters.) 

Generally  the  teeth  of  young  patients  move  easily,  but  a  con- 
siderable force  is  sometimes  required  for  the  elevation  of  the  teeth 
of  adults,  especially  of  malposed  and  impacted  incisors  and  cuspids, 
and  those  retarded  as  a  result  of  trauma.  In  correcting  these  con- 
ditions, supplemental  force  is  introduced  to  advantage.  Fig.  357 
illustrates  a  device  used  for  the  elevation  of  the  upper  teeth  when 
considerable  force  is  required.  A  metal  chin-cap  and  wire  stan- 
dards supported  by  a  cranial-cap  is  made  as  described  in  connection 
with  Fig.  144.  To  the  lower  margin  of  the  chin-cap  is  attached  an 
adjustable  knob.  A  strong  collar  with  a  tube,  eyelet,  or  flange, 
soldered  usually  on  the  labial  side,  is  cemented  to  the  tooth  to  be 
moved.  A  small  wire.  No.  18  gauge,  is  shaped  to  hook  into  the  tube, 
and  a  loop  formed  to  extend  outward  and  downward  over  the  lower 
lip  to  rest  on  the  front  of  the  chin-cap.  Through  the  loop  of  this  wire 
is  passed  a  rubber  band,  or  one  end  of  a  coiled  spring,  extending 
downward  and  held  by  the  knob.  The  amount  of  tension  is  gov- 
erned by  the  requirement  of  the  case.  Always  begin  with  slight 
force  and  increase  it  gradually,  the  wire  being  of  sufflcient  length 
to  permit  the  use  of  a  band  of  small  diameter.  The  force  is  to  be 
increased  by  using  a  heavier  band,  thus  preventing  the  too  sudden 
movement  of  the  tooth  and  stretching  of  the  pulp,  obviating  the 
danger  of  strangulation. 

A  similar  device,  with  apparatus  in  the  mouth,  was  employed  in 
the  case  of  Miss  B.,  aged  twenty-three  years.  The  right  upper  cen- 
tral incisor  was  considerably  shorter  than  the  adjoining  teeth.  The 
history  was  somewhat  obscure.  The  patient  thought  that  the  tooth 
was  gradually  settling  back  into  the  socket.  On  very  close  inquiry, 
it  was  ascertained  that  some  years  previously  a  blow  had  been  re- 
ceived on  the  tooth.  From  a  radiograph  it  was  found  that  the  root 
was  straight  and  that  no  adhesions  were  perceptible,  but  it  was 
evident,  from  the  ankylosed  condition,  that  the  peridental  membrane 
had  been  injured,  and  in  the  healing  process  a  bony  deposit  had  taken 


Fig.  357. 


\ 


J*- 


ELEVATION   OF  INCISORS  305 

place,  connecting  the  root  with  the  process.  (Figs.  30  and  31  illus- 
trate a  case  of  injury  with  the  roots  deflected.)  Luxation  of  the 
tooth  was  advised,  but  the  j)ationt  objected.  Rubber  rings  with  the 
apparatus  were  applied  in  the  manner  described,  tlie  force  being  in- 
creased gradually  until  two  heavy  umbrella  rings  were  employed, 
being  worn  at  night  and  several  hours  during  the  day.  The  tooth 
has  been  elevated  somewhat,  but  at  the  present  writing  is  not  in 
satisfactory  position. 

For  the  elevation  of  lower  teeth,  supplemental  force  can  be  applied 
with  the  apparatus  illustrated,  by  soldering  a  spring  to  the  front  of 
the  chin-cap,  the  spring  being  suitably  formed  to  pass. over  the  lower 
lip  and  attached  to  the  teeth.  The  chin-cap  is  sustained  by  a  rubber 
band  extending  from  either  side  of  the  cranial-cap,  the  tension  being 
increased  by  changing  the  adjustable  knobs  on  the  standards,  or 
using  a  heavier  band. 


20 


CHAPTER   XVII 

INCISORS,   TO    MOVE    BODILY 

Lateral  Bodily  Movement  of  Incisors. — Procedures  to  c?,use  the 
lateral  movement  of  the  roots  of  the  incisors  through  the  alveolar 
process  have  been  known  to  the  profession  for  several  years.*  The 
operation  consists  in  moving  the  root  and  crown  of  the  tooth  in  the 
same  direction,  the  alveolar  process  being  absorbed  for  the  move- 
ment. 

Formerly  this  manner  of  moving  the  teeth  was  utilized  principally 
for  drawing  together  upper  incisors  that  had  erupted  considerably 
apart,  and  for  the  correction  of  cases  where,  from  continued  devel- 
opment of  the  jaw  and  process  after  the  eruption  of  the  incisors,  the 
space  between  them  had  become  unduly  broad,  the  roots  of  the 
teeth  in  their  alveoli  being  farther  apart  than  should  be  to  permit 
the  crowns  to  take  a  proper  relative  position  when  drawn  together 
with  an  ordinary  apparatus. 

The  best  method  of  treatment  for  these  conditions  can  only  be 
determined  by  a  careful  study  of  the  case  at  hand.  When  the  space 
between  the  teeth  is  very  broad,  it  is  generally  the  wiser  plan  to 
insert  one  or  more  artificial  teeth  supported  by  a  carefully  adjusted 
appliance.  When  the  artificial  teeth  do  not  present  a  pleasing 
appearance,  sometimes  the  space  can  be  increased  to  advantage  for 
the  admission  of  wider  teeth. 

If  the  incisors  are  to  be  moved  a  considerable  distance,  and  force 
is  applied  with  an  ordinary  device,  the  crowns  are  made  to  incline 
towards  one  another  without  materially  moving  the  upper  third  of 
their  roots.  The  teeth  in  this  position  have  a  very  unpleasing 
appearance. 

Dr.  Farrar  in  his  work  on  Irregularities,  describes  a  novel  device 
for  moving  the  roots  of  tlie  incisors  with  the  crowns  laterally  towards 
one  another.  Around  the  crowns  of  the  teeth  to  be  moved,  and 
near  the  gum  line,  he  passes  a  clamp-band  made  of  a  narrow  strip 
of  thin  plate-metal,  the  ends  connected  wilh  a  threaded  bolt  and 

*  Farrar,  Dental  Cosmos,  1882,  p.  190. 
30C 


LATERAL  BODILY  MOVEMENT  OF  INCISORS  307 

nut  in  such  a  manner,  that  hy  turning  the  nut  the  band  will  be 
shortened.  A  secondary  screw  is  arranged  between  ttie  crowns  of 
the  teeth  near  their  incisive  edge  so  that  it  can  be  turned,  per- 
mitting the  ends  of  the  crowns  to  approach  one  another  as  the  roots 
are  drawn  togetlier  by  the  clamp-band,  the  intention  being  to  have 
the  roots  and  crowns  of  the  teeth  remain  parallel  to  one  another, 
or  in  the  same  relationship  throughout  tiieir  movement. 

An  ai)pliance  tliat  I  have  devised  for  moving  the  teeth  bodily  is 
shown  in  Fig.  358.     The  upper  central  incisors  were  erupted  with  a 

Fig.  358. 


considerable  space  between  them,  having  assumed  a  position  close  to 
the  cuspids,  the  lateral  incisors  being  absent. 

A  strong,  broad  collar  is  adjusted  to  each  of  the  central  incisors. 
To  the  labial  side  of  each  of  the  collars  is  soldered  horizontally  a 
short  tube  with  one  end  even  with  the  distal  surface  of  the  collar. 
By  the  side  of  each  of  the  tubes  is  attached  one  end  of  a  stiff  wire 
arm  long  enough  to  span  the  space  between  the  teeth  and  to  pass 
through  the  tube  on  the  opposite  collar.  Both  of  the  collars  are 
cemented  to  the  teeth  at  the  same  time,  the  arms  resting  parallel, 
with  the  free  ends  passing  through  the  tubes.  By  this  device  the 
teeth  are  held  continuously  in  the  same  relationship  while  being 
moved  together  and  retained. 

Force  is  usually  applied  by  means  of  a  thread  cut  on  the  free 
ends  of  the  arms,  on  which  are  run  threaded  nuts.  The  nuts  are 
turned  from  thne  to  time  for  moving  the  teeth.  As  the  teeth  approach 
each  other  the  arms  will  project  more  from  the  ends  of  the  tubes. 
If  they  interfere  with  the  action  of  the  lip,  they  can  be  cut  off  or  bent 
backward.  When  desired,  a  spring  rather  than  a  screw  can  be  util- 
ized for  applying  the  force,  the  spring  being  formed  and  attached  to 
a  base-wire  ;  or  a  suitably  shaped  spring  can  be  used  in  addition  to 
the  long  arms.  (See  Figs.  287  and  288.)  Cord  ligatures  or  rubber 
bands  may  be  used,  but  their  movement  is  not  so  regular,  and  more 
attention  is  required  to  obtain  the  desired  result. 

The  attachment  of  a  long  tube  on  the  front  of  each  collar,  through 


308 


INCISORS 


which  is  passed  a  threaded  bolt  with  a  thick  nut  and  a  strong  thread 
for  causing  traction,  is  appUcable  when  the  teeth  are  to  be  moved 
but  a  short  distance. 

The  too  rapid  movement  of  the  teeth  is  always  objectionable. 
The  alveolar  process  is  gradually  absorbed  as  the  roots  of  the  teeth 
are  moved  towards  one  another,  and  if  the  apices  of  the  roots  are 
moved  too  rapidly  through  the  process  there  is  always  danger  of 
strangulation  of  their  pulps.  Especially  is  this  the  case  with  the 
adult,  as  the  process,  being  more  dense,  is  not  absorbed  so  readily. 

In  young  patients,  when  the  roots  of  the  central  incisors  diverge 
to  such  an  extent  as  to  give  an  unpleasant  appearance  of  the  crowns 
of  the  teeth,  they  can  be  forced  together  with  a  device  as  illustrated 
in  Fig.  359.  A  collar  Avith  a  tube  soldered  perpendicularly  on  the 
mesio-labial  surface  is  cemented  to  each  of  the  incisors.  The  ends 
of  a  spring- wire  are  bent  at  a  r^ht  angle,  making  the  width  between 


Fig.  359. 


Fig.  360. 


the  parallel  sides  equal  to  the  width  of  the  two  teeth.  The  anus  of 
the  spring  are  then  bent  towards  each  other,  and  again  bent  sharply 
at  a  right  angle  towards  the  main  portion  of  the  spring  to  pass 
through  the  tubes,  usually  from  above  downward,  leaving  the  body 
of  the  spring  to  pass  close  underneath  the  ends  of  the  tubes.  To 
draw  the  roots  together  force  is  caused  by  bending  the  ends  of  the 
spring  slightly  from  time  to  time  where  they  enter  the  tubes,  bend- 
ing them  laterally  from  the  median  line  in  the  direction  of  the  dotted 
lines. 

This  device  may  be  used  for  separating  the  roots  of  the  incisors 
when  desirable,  as  in  case  of  divei^ng  crowns  (Fig.  360).  In  such  a 
case  the  tubes  on  the  collars  should  be  located  on  the  labio-distal 
surface,  and  the  spring  made  with  a  loop  in  the  centre,  the  ends 
bent  outward  and  again  downward  at  a  right  angle  to  enter  the 


LATERAL  BODILY  MOVEMENT  OF  INCISORS  309 

tubes.  Force  is  got  by  bending  tlie  ends  of  the  spring  where  they 
enter  the  tubes  a  Uttle  at  a  time  towards  each  otiier  in  the  direction 
of  the  dotted  Unes.  It  is  essential  that  the  sj)ring  be  fitted  carefuHy  to 
place,  to  cause  pressure  only  in  the  direction  required  as  force  is 
applied.  Bend  the  ends  of  the  spring  slightly  at  a  time,  and  equally, 
to  prevent  the  lengthening  of  either  of  the  teeth.  The  centre  loop 
of  the  spring  may  be  opened  by  bending  when  desired  for  increasing 
the  distance  between  the  crowns,  or  vice  versa.  The  teeth  should 
be  retained  a  long  time.  Generally  the  same  or  a  similar  device  is 
suitable. 

When  the  lower  incisors  in  the  process  of  eruption  assume  a  fan- 
shape,  with  the  apices  of  the  roots  crowded  together  (Fig.  361),  they 
can  sometimes  be  forced  into  a  normal  position  jtig  361 

as  respects  the  base  of  the  alveolar  ridge  by  a 
device  similar  to  the  one  previously  described. 
A  collar  with  a  perpendicular  tube  on  the  labial 
side  is  cemented  to  each  of  the  lateral  incisors, 
the  tubes  being  placed  near  the  labio-distal  sur- 
face. A  spring-wire  is  bent  into  a  short  U-shaped  loop  to  rest 
opposite  the  central  incisors ;  the  ends  extend  outward  and  are 
bent  downward  at  a  right  angle  to  enter  the  tubes.  Force  is  applied 
by  bending  the  ends  of  the  spring  outward  slightly,  and  when  neces- 
sary adjusting  the  length  of  the  spring  by  changing  the  width  of  the 
U-shaped  loop,  which  moves  the  roots  laterally  from  the  median  line 
to  an  upright  position.  If  the  appearance  of  the  central  incisors  is 
not  sufficiently  improved  by  the  manipulation,  they  can  be  corrected 
in  a  similar  manner. 

Early  in  practice  I  moved  tlie  incisor  teeth  bodily,  both  anteriorly 
and  posteriorly,  without  changing  their  angle.  (See  Dental  Cosmos, 
1887,  page  385,  and  1888,  page  512.) 

In  but  a  small  percentage  of  the  cases  presented  for  treatment 
requiring  the  incisors  to  be  moved  outward  or  inward  is  it  found 
necessary  to  adapt  special  apparatus  and  move  them  bodily,  and 
again  but  a  few  of  the  cases  that  are  so  treated  meet  the  full  ex- 
pectations of  the  operator,  especially  when  the  operation  is  per- 
formed upon  an  adult.  After  the  teeth  and  bone  have  been 
moved,  in  the  healing  process  there  is  always  a  contraction  similar 
to  the  contraction  of  scar  tissue  after  a  wound ;  and  if  an  ordinary 
retainer  is  applied  which  does  not  hold  the  teeth  bodily,  this  condi- 


310  INCISORS 

tion  will  force  the  roots  of  the  teeth  towards  their  original  position, 
which  gives  an  unpleasant  appearance  of  their  crowns.  Moving  all 
of  the  incisors  outward  at  one  time  by  force  applied  to  their  crowns 
carries  more  or  less  of  the  alveolar  process  with  them,  particularly 
the  outer  table.  With  young  patients  the  stretching  of  the  pre- 
maxillary  bone  encourages  its  development.  The  suture  between 
the  premaxillary  and  the  palatal  processes  of  the  maxillary  bones  is 
not  fully  united  in  early  childhood.  Flat  bones  grow  from  their 
edges.  The  premaxillary  may  be  numbered  with  this  class ;  during 
its  development  it  can  be  encouraged  by  pressure  to  take  on  a  dif- 
ferent form,  and  therefore  better  results  are  obtained  if  the  change 
is  made  w^hile  the  alveolar  process  and  jaws  are  in  this  active  stage 
of  development.  In  any  case,  the  continued  retention  of  the  teeth 
in  their  new  position  for  a  considerable  length  of  time,  to  permit  the 
process  to  become  firm  around  them,  is  essential.  This  is  sometimes 
difficult  to  accomplish  while  the  bones  and  process  are  still  develop- 
ing and  before  the  bicuspids  are  fully  erupted.  Space  for  the  accom- 
modation of  the  permanent  cuspids  should  be  constantly  preserved. 
If  the  deciduous  cuspids  are  absent,  with  insufficient  room  for  the 
permanent  ones  at  about  the  time  of  their  eruption,  the  case  should 
be  carefully  examined  to  determine  whether  the  roots  of  the  lateral 
incisors  are  sufficiently  in  front  of  the  incoming  cuspids  to  permit 
the  latter  to  take  a  correct  position.  The  roots  of  the  lateral  incisors 
are  somewhat  flattened  laterally,  and  they  should  be  located  so  that 
the  incoming  cuspids  will  not  rotate  them.  These  precautions  are 
necessary  when  the  anterior  region  of  the  upper  arch  is  not  suffi- 
ciently prominent  to  harmonize  the  features.  It  is  difficult  some- 
times to  determine  fully  before  the  tenth  or  twelfth  year  how  the 
jaws  are  going  to  harmonize  as  to  their  fulness,  and  when  the  de- 
formity is  not  very  marked  it  is  usually  advisable  to  defer  operating 
until  a  satisfactory  diagnosis  can  be  made. 

Outward  Bodily  Movement  of  Incisors. — The  first  appliance  that 
I  devised  for  moving  the  teeth  bodily  outward  was  made  for  im- 
proving the  position  of  four  upper  incisors.  A  metal  cap  of 
No.  29  gauge,  made  with  accurate  metal  dies,  was  attached 
to  the  incisors  (Fig.  64).  To  the  lingual  side  of  the  cap  near  the 
gum  were  soldered  two  heavy  wire  arms,  extending  backward  and 
following  tlie  inner  curve  of  the  arch,  one  on  either  side,  near  the 
bicuspids  and  molars.      Holes  were  made  in  tlie  labial  and  lingual 


OUTWARD  BODILY  MOVEMENT  OF  INCISORS  311 

sides  of  the  cap,  in  position  to  accommodate  wire  ligatures  passing 
between  the  teeth  near  the  margin  of  the  gum.  The  cap  was 
fastened  to  the  teeth  by  tirst  passing  the  Hgatun-s  between  them 
and  the  holes  in  the  edge  of  the  cap,  drying  the  teeth  carefully, 
and  setting  the  cap  with  cement,  hastily  drawing  the  ligatures  up 
firmly  and  twisting  their  ends.  The  anchorage  for  moving  the  teeth 
was  secured  by  shaping  a  partial  vulcanite  plate  to  the  palatine 
arch,  covering  the  arms  described.  In  these  jjlaces  the  plate  was 
thickened,  forming  grooves,  extending  from  front  to  back  on  the 
lingual  side,  for  the  accommodation  of  the  arms. 

The  jjlate  was  retained  with  wire-clasps  passing  around  the  first 
bicuspids  and  first  molars.  Each  arm  had  a  small  projection  or 
knob  soldered  to  the  side  of  it,  made  long  enough  to  project  through 
the  surface  of  the  plate  to  engage  with  springs  for  supplying  the 
force,  the  plate  being  dressed  away  in  these  parts  down  to  the 
grooves  to  expose  the  knobs,  and  to  form  a  short  slot  in  front  of 
them  to  permit  the  movement.  Two  springs  for  this  purpose,  one 
on  either  side,  w^ere  attached  in  the  anterior  third  of  the  plate,  and 
shaped  in  a  double  curve  to  extend  back  of  and  engage  with  the 
distal  side  of  the  knobs  on  the  arms,  thus  giving  the  desired  pressure 
forward. 

Several  methods  of  making  attachment  to  the  teeth  will  be  de- 
scribed. To  the  incisors  a  fixed  attachment  may  be  made  with 
collars,  soldering  to  them  a  heavy  lingual  base-wire,  with  the  ends 
extending  backward  in  the  form  of  arms ;  or  by  arranging  on  the 
inner  curve  of  each  side  of  the  arch  a  forked  arm,  one  of  the  forks 
being  soldered  to  a  broad  collar  previously  fitted  to  the  central,  and 
the  other  soldered  to  a  similar  collar  on  the  lateral.  With  the  arms 
forked  in  this  manner,  the  collars  are  easily  adjusted  for  cementing. 
The  free  ends  of  the  arms  project  backward  to  be  supported,  and 
engage  with  springs  in  a  plate  in  the  manner  mentioned ;  or  force 
can  be  applied  from  a  metal  anchorage.  To  make  the  long  arms 
removable  for  cleansing,  etc.  (Fig.  362),  solder  a  strong  short  arm  to 
the  lingual  side  of  each  of  the  collars,  or  to  a  metal  cap,  the  arms 
pointing  backward  parallel  one  with  the  other,  to  project  into  strong 
tubes  attached  to  a  lingual  base-wire,  or  to  forked  arms.  The  tubes, 
if  required,  should  be  a  little  larger  in  the  mesio-distal  diameter  to 
allow  for  any  side  variation  in  the  line  of  the  posts,  and  to  permit 
of  easy  removal.      This  connection  can  be  made  in   the  reverse 


312  INCISORS 

manner  by  soldering  the  tubes  to  the  coHars,  and  the  arms  shaped 
to  project  into  the  tubes.  The  anchorage  usually  consists  of  spring- 
clasp  attachments  to  the  tirst  bicuspids  and  first  molars,  the  sides 
being  connected  by  a  palatine  base-wire.     Each  end  of  the  base- 

FiG.  362. 


wire,  a  tube,  and  one  end  of  a  U-shaped  spring  pointing  towards  the 
roof  of  tlie  mouth,  are  soldered  to  the  partial-clasps  opposite  the 
molars,  the  tubes  being  properly  placed  for  the  support  of  the  arms. 
Each  arm  is  provided  with  a  flange  to  engage  with  the  free  end 
of  the  spring.  Force  is  applied  by  bending  the  ends  of  the  springs 
forward. 

Later  the  system  of  attachment  of  the  arms  to  the  teeth  was  sim- 
plified by  soldering  horizontally  to  the  lingual  side  of  each  of  the 
collars  a  small  loop  of  flat  or  round  metal,  to  engage  with  suitably 
shaped  spurs  projecting  downward  and  forward  from  the  anterior 
part  of  a  lingual  base- wire.  This  attachment  is  in  effect  like  a  hinge 
that  comes  to  a  full  stop  when  the  distal  part  of  the  arm  is  pressed 
into  place.  It  holds  the  teeth  in  the  same  relationship  to  the  base- 
wire  when  force  is  api^lied,  but  it  is  easily  unhooked  for  removal. 

This  form  of  attachment  is  also  available  for  moving  the  incisors 
bodily  inward  by  reversing  the  hinged  attachment  of  the  base-wire 
arms,  having  the  loops  or  eyelets  near  the  necks  of  the  teeth. 

Fig.  303  illustrates  another  method  of  making  an  attachment  on 
this  principle.  To  each  of  the  incisors  to  be  moved  is  cemented  a 
collar  with  a  hook-shaped  flange  on  the  lingual  side  nearly  as  broad. 
as  the  width  of  the  tooth,  and  bent  at  a  right  angle  towards  the 


OUTWARD  BODILY   M()VEMP:NT  OF  INCISORS 


313 


gum  to  engage  with  spurs  })rojecting  downward  frcjiu  a  lingual  base- 
wire.  The  base-wire  is  forced  forward  with  a  spring  device,  as  in 
Fig.  309. 

When  the  incisors  are  nearly  in  a  line,  cementing  to  them  a 
swaged  metal  cap,  covering  all  of  the  teeth  to  be  moved,  is  some- 
times preferable  to  the  use  of  collars  (Fig.  304).     The  base-wire  is 


Fig.  364. 


attached  to  the  cap  in  an  adjustable  manner  by  soldering  one  or 
more  loops  to  the  lingual  side  of  the  cap  to  engage  with  spurs  on  a 
base-wire.  One  loop  should  be  placed  at  the  median  line,  and  a 
shelf-like  projection   near  each   of  the  distal  yig.  365. 

ends  to  support  and  hold  the  cap  and  bar  in 
the  same  relationship  as  force  is  applied;  or  a 
short  post  may  be  soldered  to  the  disto-lingual 
sides  of  the  cap  to  engage  with  tubes  on  the 
base-wire. 

Another  method  of  making  this  connection 
is  illustrated  in  Fig.  365.  A  large  semicircular 
wire  is  soldered  to  the  lingual  side  of  the  cap 
near  the  gum,  with  the  ends  projecting  a  little. 
To  a  lingual  base- wire  of  the  same  curve  is 
attached  one  or  more  flanges  that  i)roject  up- 
ward and  curve  outward  to  engage  Avith  the  upper  surface  of  the 
semicircular  wire  attached  to  the  cap,  the  base-wire  being  removable 
as  described.  As  force  is  applied,  the  flanges  lock  with  the  semi- 
circular wire  on  the  cap. 

Several   variations   from   these   forms   of  attachment   have  been 
devised.     One  that  has  proved  convenient  is  made  by  soldering  two 


314  INCISORS 

horizontal  planes  to  the  lingual  side  of  a  cap,  as  illustrated  in  Fig. 
366.     The  planes  are  formed  of  two  pieces  of  plate-metal  cut  on  a 
Fig  306  curve,  the  space  between  the  planes  being  just 

sufficient  to  pass  either  side  of  the  base-wire. 

This  form  of  cap  was  employed  in  moving 
the  upper  incisors  outward  bodily  for  Miss  S., 
aged  seventeen  years.  The  history  of  this 
case  is  interesting.  Fig.  367  illustrates  a  cast  of  the  features  be- 
fore regulation.  The  patient  had  been  afflicted  with  nasal  disease 
since  childhood.  There  was  a  lack  of  development  of  the  upper 
maxilla ;  the  region  of  the  face  about  the  upper  lip  was  much  de- 
pressed and  wanting  in  rotundity.  The  incisors  were  rather  regu- 
lar, with  the  lateral  incisors  standing  a  little  back  of  the  line  of  the 
centrals  (Fig.  368).  The  lateral  on  the  right  side  rested  in  contact 
with  the  first  bicuspid,  the  cuspid  having  erupted  anterior  to  them. 
On  the  left  side  the  cuspid  was  also  very  prominent,  with  a  narrow 
space  between  the  lateral  incisor  and  first  bicuspid.  The  upper  in- 
cisors closed  considerably  back  of  the  lower  incisors.  The  arch  in  the 
region  of  the  bicuspids  and  first  molars  was  poorly  developed,  being 
considerably  narrower  than  that  of  the  lower  arch,  with  only  two  or 
three  teeth  occluding. 

The  patient  was  extremely  anxious  to  have  the  deformity  corrected, 
and  was  referred  to  me  after  having  applied  to  several  prominent 
operators  for  treatment.  One  practitioner  advised  the  extraction 
of  the  cuspids  ;  others  said  that  nothing  could  be  done. 

The  metal-cap  accurately  made  with  dies  was  cemented  to  the 
incisors  to  be  moved.  For  anchorage  a  spring-clasp  attachment 
was  formed  over  the  first  bicuspid  and  the  first  molar  on  either 
side  of  the  arch,  and  partial-clasps  on  the  second  bicuspids  and 
second  molars  (Fig.  369).  These  parts  were  connected  with  a  pala- 
tine base-wire  crossing  the  arch  opposite  the  distal  surface  of  the 
first  molars,  with  the  ends  bent  at  right  angles  to  rest  on  the  partial- 
clasps.  By  each  end  was  attached  a  tube  for  holding  the  curved 
arms  of  a  lingual  base-wire.  All  was  united  by  solder,  joining  at 
the  same  time  the  spring-clasps,  partial-clasps,  base-wire,  and  tubes, 
and  also  tw^o  springs  for  causing  force,  one  on  either  side.  These 
were  formed  into  U-shaped  loops  resting  in  front  of  the  base-wire, 
and  made  to  point  upward  into  the  arch  towards  the  median  line 
following  the  jjalatal  curve.     One  end  of  the   spring  being  united 


Fk;.  3<)7. 


Fig.  368. 


OUTWARD   BODILY   MOVEMENT   OF  INCISORS 


315 


with  solder  to  tlio  baso-wiro  near  the  tubes,  the  other  end  projected 
above  and  was  made  to  catcli  ba(;k  of  a  knob  tliat  was  soldered 
on  the  side  of  the  arms.  All  of  the  appliance  except  the  metal  cap 
over  the  incisors  was  removable  by  first  unhooking  the  springs  from 
the  knobs,  and  sliding  the  arms  backward  through  the  tubes  suffi- 
ciently to  disengage  the  curved  portion  of  the  lingual  base-wire  from 
the  groove  formed  by  the  planes  on  the  cap,  and  drawing  down- 
ward on  the  spring-clasp  attachments.  The  appliance  was  removed 
daily  by  the  patient  for  cleansing. 

The  necessary  force  for  moving  the  incisors  outward  was  applied 
by  opening  the  loops  in  the  springs  by  bending,  and  again  springing 

Fig.  369. 


the  ends  back  of  the  knobs  on  the  arms.     The  changes  were  made 
at  first  about  once  a  week,  and  later  not  as  often. 

The  appliance  as  shown  in  the  figure  was  inserted  on  April  26, 
and  by  the  constant  gradual  force  applied  the  incisors  were  moved 
outw-ard,  as  seen  in  Fig.  370,  on  September  8,  when  it  was  found 
advisable  to  commence  expanding  the  arch  laterally.  For  this  the 
same  apparatus  was  employed  by  simply  cutting  a  narrow  section 
from  the  heavy  palatine  base-wire  that  crossed  the  arch,  and  solder- 
ing to  the  remaining  ends  the  ends  of  a  U-shaped  loop  of  wire  of 
the  same  size  for  forming  a  spring  as  seen  in  the  figure.  It  will  be 
readily  understood  that  it  would  not  have  been  advisable  to  com- 
mence expanding  the  arch  laterally  by  moving  the  bicuspids  and 
molars  outward  until  after  the  incisors  had  been  moved  outward 


316 


INCISORS 


nearly  as  far  as-  it  was  intended  thej'  should  go,  as  the  teeth  for  an- 
chorage, having  been  once  moved,  Avould  not  form  a  sufficiently- 
fixed  point  of  resistance  for  causing  the  required  force. 


Fig.  370. 


The  arch  was  expanded  by  bending  the  loop  in  the  palatine  spring 
base-wire,  broadening  it  slightly,  and  at  the  same  time  aiding  the 
force  by  bending  outward  the  sides  of  the  lingual  sliding  base-wire 

Fig.  371. 


forming  the  arms.  The  metal  cap  had  not  been  removed  from  the 
incisors.  It  will  ])(;  remembered  that  the  lateral  incisors  originally 
held  a  ])Osition  a  little  back  of  the  line  of  the  centrals.     When  the 


Fi<i. 


Fi<!.  373. 


OUTWARD  BODILY   MOVEMENT  OP^  INCISORS  317 

arcli  was  nearly  expanded  they  wore  moved  outward  into  line  by 
cutting  away  a  })ortion  of  the  metal  cap  just  in  front  of  them  and 
forcing  absorbent  cotton  between  them  and  the  cap  on  the  lingual 
side.  The  lateral  incisors  gained  a  correct  position  at  about  the  lime 
the  arch  was  sufficiently  expanded.  Fig.  371  illustrates  the  appa- 
ratus, the  expanded  condition  of  the  arch,  and  the  position  of  the 
teeth  on  the  following  May  14. 

The  remaining  portion  of  the  cap  was  removed  from  the  incisors, 
and  for  retaining  them  a  larger  cap,  to  include  the  cuspids,  was  made 
of  gold  plate,  and  cemented  firmly  to  place  (Fig.  509). 

To  retain  the  teeth  of  the  distal  part  of  the  arch  a  vulcanite  plate 
was  made  to  cover  the  palatine  portion,  fitted  well  to  the  gold  cap 
and  to  the  necks  of  the  teeth. 

As  was  natural  after  this  extreme  expansion,  the  teeth  of  the  upper 
arch  (lid  not  occlude  as  well  as  was  desired  with  those  of  the 
lower,  and  a  chin-cap  for  pressing  the  teeth  of  the  lower  jaw  forcibly 
against  those  of  the  upper  w^as  used,  as  shown  in  Fig.  372,  the 
apparatus  being  worn  at  night  and  as  many  hours  as  convenient 
during  the  day  for  a  few  weeks,  then  regularly  at  night.  By  this 
means  the  teeth  settled  together  so  that  an  even  and  good  occlusion 
was  secured.  The  plate  and  gold  cap  over  the  incisors  was  worn 
continuously  for  over  two  years,  the  case  being  examined  frequently 
and  the  cap  reset  three  times.  The  patient  was  instructed  to  con- 
tinue the  use  of  the  palatine  plate  and  the  chin-cap  for  a  longer 
time. 

A  metal  cap  with  two  horizontal  planes  similar  to  Fig.  366,  with 
an  appliance,  was  utilized  for  moving  outward  bodily  two  upper 
central  incisors  for  Mr.  A.,  aged  twenty-two  years.  The  lateral 
incisors  had  been  extracted  years  before  by  an'  inexperienced  prac- 
titioner. The  cap  was  fitted  to  the  incisors  and  the  horizontal 
planes  attached  to  the  lingual  side.  The  one  next  the  gum  was 
made  of  stiff  metal  and  rather  broad,  extending  backward  opposite 
the  cuspids  in  the  same  curve  as  the  base- wire.  The  base-wire  rested 
on  this,  passing  between  the  planes  as  before,  which  gave  a  suitable 
bearing  for  moving  the  incisors.  After  regulation  a  plate  with  two 
lateral  incisors  was  applied  to  fill  the  spaces  and  retain  the  centrals. 

In  moving  teeth  outward,  especially  in  moving  them  bodily,  con- 
siderable force  is  sometimes  required.  When  desirable,  supplemental 
force  can  be  applied  (Fig.  373).     To  the  labial  side  of  a  metal  cap 


318 


INCISORS 


over  the  teeth  or  to  collars  is  soldered  an  eyelet  or  other  shaped 
device  for  the  attachment  of  a  supralabial  bar.  A  chin-cap  is  sup- 
ported by  wire  standards  and  a  cranial-cap.  To  the  band  of  the 
cap  on  each  side  is  attached  one  end  of  a  suitably  sized  tube  extend- 
ing downward  in  front  of  the  ear  ;  into  this  tube  the  wire  standard  is 
made  to  pass.  To  the  lower  end  of  the  tube  is  attached  an  ad- 
justable knob,  and  another  to  the  standard  below  the  end  of  the 
tube.  Over  the  knobs  is  passed  a  rubber  band.  The  lower  knob  is 
located  so  as  to  give  just  enough  tension  of  the  elastic  to  retain  the 
apparatus  in  place  when  in  use.  The  supralabial  bar  is  made  of 
wire,  No.  12  gauge  or  larger,  formed  to  pass  in  front  of  the  face, 
with  a  U-shaped  loop  arranged  near  each  end,  extending  upward  or 
downward  in  front  of  the  standards.  To  each  end  of  the  wire  is 
soldered  a  rigid  piece  of  plate-metal  that  has  a  deep  notch  cut  into 
the  distal  edge  (Fig.  374,  a,  a)  sufficiently  large  to  hook  onto  the 
adjustable  knobs  of  the  standards  for  holding  the  bar  in  place;  or. 

Fig.  374. 


instead  of  the  plate-metal,  the  ends  of  the  wire  may  be  bent  into 
the  form  of  a  hook  to  engage  with  the  knobs.  At  the  centre  of 
the  supralabial  bar  is  attached  a  wire  {b)  shaped  suitably  to  hook 
into  the  tube,  eyelet,  or  other  form  of  attachment.  Force  is  applied 
by  opening  the  loops  of  the  supralabial  bar  a  little  at  a  time.  Too 
much  force  or  force  too  suddenly  applied  is  always  objectionable. 
The  adjustable  knobs  can  be  moved  up  or  down  on  the  tubes  for 
improving  the  Hne  of  traction.  The  wire  standards  passing  into 
tubes  in  this  manner  permit  the  movement  of  the  lower  jaw  without 
interfering  detrimentally  with  the  action  of  the  supralabial  bar  when 
it  is  used  for  either  anterior  expansion  or  the  contraction  of  the  arch. 
Fig.  370  shows  the  jjosition  of  the  teeth  of  Mr.  S.,  aged  twenty- 
two  years. "^  The  up]jer  maxilla  was  not  sufficiently  developed  ante- 
riorly.    The  arch  was  narrow  and  very  deep,  and  the  upper  incisors 


*  Jackson,  Denial  Cosmos,  1890,  p.  879. 


OUTWARD  BODILY  MOVEMENT  OF  INCISORS 


319 


closed  far  back  of  the  lower  ones,  measuring  three-fourths  of  an  inch 
from  the  lingual  side  of  the  upper  laterals  to  the  labial  surface  of 


Fig.  375. 


the  lower  laterals  and  cuspids.  The  lateral  incisors  were  near  the 
first  bicuspids,  causing  an  extreme  depression  in  the  region  of  the 
incisors,  and  the  lower  jaw  was  excessively  prognathous. 

The  patient  had  suffered  with  nasal  disease  since  childhood,  and 
had  had  several  operations  performed.  The  upper  teeth,  together 
with  both  the  inner  and  outer  table  of  the  alveolar  process,  were 
moved  outward  by  the  use  of  a  modified  Coffin  plate  (Fig.  376). 
The  plate  was  made  to  cover  the  palatine  portion  of  the  arch,  fitting 

Fig.  376. 


well  about  the  necks  of  the  molars,  bicuspids,  and  the  incisors  to  be 
moved.  It  was  designed  to  separate  the  plate  laterally  in  two  parts, 
having  them  connected  with  spring-wires,  with  the  anterior  part  about 
as  broad  and  long  as  the  palatine  portion  of  the  intermaxillary  bone 
back  of  the  incisors.    The  divisions  of  the  plate  were  connected  with 


320  INCISOES 

two  spring-wires,  No.  16  gauge  (a  larger  size  is  sometimes  prefer- 
able), each  being  formed  into  three  partial  U-shaped  loops,  with  the 
ends  flattened  to  make  a  good  anchorage  in  the  vulcanite.  In  making, 
a  try-plate  of  wax  was  first  formed  as  in  an  ordinary  case,  and 
several  pieces  of  binding  wire  placed  around  each  spring,  with  the 
ends  projecting  upward,  so  that  when  the  plaster  Avas  poured  in  the 
upper  half  of  tlie  flask  it  surrounded  the  ends  of  the  binding  wire 
and  held  the  spring  in  position  when  it  was  removed  for  packing 
the  rubber.  The  surface  of  the  wax  was  marked  where  it  was 
intended  to  separate  the  plate  when  finished. 

The  ends  of  the  springs  were  arranged  in  the  parts  of  the  plate  so 
that  the  centre  loops  rested  towards  the  median  line.  The  plate 
was  anchored  with  wire-clasps,  and  collars  with  lugs,  having  clasps 
extending  around  the  mesial  and  buccal  surface  of  the  first  bicuspids, 
and  similar  clasps  extending  from  the  distal  part  over  the  arch  at 
the  junction  of  two  of  the  teeth  to  rest  on  the  buccal  side  of  the 
second  molars.  The  anterior  part  w^as  anchored  by  cementing  to 
each  of  the  lateral  incisors  and  one  of  the  centrals  a  gold  collar 
with  a  broad  lug  on  the  lingual  side,  shaped  to  project  over  the  edge 
of  the  plate.  After  the  plate  was  finished  it  was  divided  with  a  fine 
saw,  following  the  line  indicated  on  the  surface,  and  the  edges  prop- 
erly smoothed. 

Gradual  force  was  applied  by  opening  the  loops  slightly  in  the 
.springs  by  bending,  the  changes  being  made  about  once  a  week. 
The  part  covering  the  intermaxillary  portion  was  kept  in  an  inclined 
position  most  favorable  for  pushing  the  process  bodily  outward,  the 
plate  being  removed  by  the  patient  twice  a  day  for  thorough  cleans- 
ing. A  continuation  of  this  case  will  be  found  on  page  324. 
Fig.  379  shows  the  position  of  the  teeth  after  the  plate  had  been 
worn  six  months. 

Inward  Bodily  Movement  of  Incisors. — The  bodily  movement  in- 
ward of  prominent  teeth  and  the  process  is  conducted  on  the  same 
principle  as  for  moving  them  outward,  the  object  being  to  reduce 
the  prominence  in  the  incisive  region  for  iiui^roving  the  facial  con- 
tour, the  occlusion,  appearance,  and  angle  of  the  teeth.  It  should 
be  kept  in  mind,  however,  that  the  inward  movement  of  the  upper 
incisors  and  process  does  not  usually  lesson  the  prominence  of  the 
nasal  spine  of  the  maxilla,  and  therefore  no  case  should  be  under- 
taken until  the  prospective  prominence  of  the  nose,  which  does  not 


INWARD   BODILY   MOVEMENT  OF  INCISORS  321 

come  to  full  development  until  the  age  of  maturity,  has  been  care- 
fully considered. 

Ordinary'  cases  of  protrusion  can  be  reduced  by  moving  the  teeth 
and  process  inward  w^ith  apparatus  as  described  in  Chapter  XII., 
Incisors,  to  move  Inward.  The  force  should  always  be  applied  close 
to  the  margin  of  the  gum  on  the  labial  side,  using  gradual  steady 
pressure  to  produce  the  desired  absorption  of  the  process  opposite 
the  lingual  side  of  the  roots  of  tlie  teeth.  If  the  force  is  sufficiently 
gradual,  there  is  generally  no  corresponding  tipping  forward  of  the 
apex  of  the  roots,  or  tendency  of  the  teeth  to  rotate. 

In  Fig.  377  it  will  be  seen  that,  as  force  is  applied  with  a  spring 
(a,  b)  on  the  labial  faces  of  the  incisors,  at  the  margin  of  the  gum, 

Fig.  377. 


the  teeth  will  necessarily  be  moved  inward  together  until  they  press 
against  the  lower  incisors,  or  until  they  all  touch  their  approximal 
surfaces,  resting  against  one  another  near  their  incisive  edge.  This 
will  prevent  further  inward  movement  of  their  crowns,  and  when 
gradual  force  is  continued  while  they  are  in  contact  in  this  manner, 
it  will  be  exerted  upon  their  roots,  moving  them  inward.  If 
excessive  force  is  applied  at  this  stage  it  will  cause  the  teeth  to  crimp. 

Direct  bodily  movement  inward  of  the  teeth  is  caused  by  an  appli- 
ance made  similar  to  Fig.  369,  with  reversed  action  of  the  springs; 
the  adjustable  arms  being  attached  to  collars  over  the  teeth  or  to  a 
cap  in  a  reversed  manner  from  that  shown  in  Figs.  363  and  364. 

A  device  made  of  vulcanite,  as  described  on  page  310  of  this 
chapter,  is  made  applicable  by  reversing  the  action  of  the  springs 
and  dressing  away  a  small  portion  of  the  rubber  back  of  the  teeth 
to  be  moved. 

In  the  case  of  Miss  E.,  aged  eight  years,  an  extreme  protrusion 
of  the  upper  teeth,  with  prominence  of  the  jaw  and  process,  was 
corrected.  There  was  an  apparent  recession  of  the  lower  jaw,  the 
lower  incisors  biting  against  the  soft  tissues  of  the  upper  arch. 

21 


322  INCISORS 

A  vulcanite  palatine  plate,  made  as  illustrated  in  Fig.  338,  v/as 
employed.  The  rubber  in  the  anterior  part  was  thickened  to  form 
an  inclined  plane  for  depressing  the  lower  incisors  in  their  sockets, 
they  being  considerably  extruded.  For  moving  the  incisors  and  de- 
ciduous cuspids  inward,  a  semicircular  spring  with  two  U-shaped  loops 
was  arranged  to  cross  the  labial  side  of  them,  the  ends  passing  over  the 
arch  at  the  junction  of  the  first  and  second  bicuspids  to  be  anchored 
in  the  vulcanite.  When  the  spaces  between  the  upper  incisors  and 
cuspids  were  closed  by  the  application  of  the  spring,  the  unerupted 
first  bicuspids  were  extracted,  and  a  little  of  the  anterior  margin  of 
the  plate  was  dressed  away  from  time  to  time  to  permit  their  con- 
tinued movement.  The  spring  was  placed  rather  near  the  incisive 
edge,  for  tipping  them  inward  to  the  desired  angle ;  after  which  a 
metal  cap,  with  two  wire  arms  attached  to  the  lingual  side,  was 
applied  to  the  incisors  and  deciduous  cuspids  for  moving  them  inward 
bodily.  The  cap  was  made  in  the  manner  described  in  connection 
with  Fig.  64.  For  continuing  the  depression  of  the  lower  incisors, 
a  semicircular  piece  of  plate-metal  for  forming  an  inclined  plane  was 
soldered  to  the  lingual  side  of  the  cap,  projecting  backward  and 
downward.  Two  arms  of  round  wire,  No.  12  gauge,  Avere  soldered 
to  the  cap  underneath  the  inclined  plane,  and  shaped  to  extend  one 
on  either  side,  following  the  inner  curve  of  the  arch;  they  terminated 
on  the  grinding  surface  of  the  first  permanent  molars.  The  cap  was 
then  strongly  cemented  to  the  incisors  and  cuspids.  Fig.  378  shows 
the  cap  in  position  when  the  regulation  was  nearly  completed.    The 

Fig.  378. 


arms  projecting  backward  from  the  cap  and  resting  on  the  grinding 
surface  of  the  molars  in  this  manner  prevented  the  front  teeth  from 
tipping  or  changing  their  angle  as  they  were  forced  bodily  inward. 


INWARD   BODILY   MOVEMENT  OF  INCISORS  323 

The  pressure  for  causing  their  movement  was  applied  by  a  cross-bar 
and  cranial-cap  in  the  manner  illustrated  in  Fig.  69,  the  cap  being 
worn  regularly  at  iiig-ht  and  as  many  hours  during  the  day  as 
practicable. 

Dr.  Case  has  described  a  method  of  moving  teeth  bodily,  the 
principle  of  which  is  as  follows.*  A  collar  well  fitted  to  each  of 
the  incisors  to  be  moved  has  an  arm  soldered  to  the  front,  project- 
ing near  the  gum  under  the  lip,  and  reaching  about  one-third  of 
the  length  of  the  root.  Strong  collars  are  also  fitted  to  one  or  more 
of  the  molars  on  each  side  of  the  distal  part  of  the  arch  for  an- 
chorage, with  two  tubes  soldered  in  suitable  position  on  the  buccal 
side.  The  collars  are  cemented  to  the  teeth.  Force  for  moving  the 
teeth  is  supplied  by  two  curved  bars,  made  to  extend  around  the 
labio-buccal  side  of  the  arch  and  passing  through  the  tubes.  One 
of  the  bars  is  fastened  to  the  ends  of  the  arms  projecting  upward 
from  the  collars  for  causing  the  power,  and  the  other  to  the  arms 
near  the  incisive  edge  of  the  teeth,  acting  as  a  fulcrum.  The  ends  of 
the  bars  are  provided  with  a  thread  and  nut.  Traction  for  moving 
the  teeth  bodily  inward  is  got  by  turning  the  nuts  on  the  ends 
of  the  upper  bar,  which  engages  with  the  distal  ends  of  the  tubes, 
thus  drawing  inward  on  the  arms,  while  the  low^er  bar  is  made  to 
prevent  the  inward  movement  of  the  lower  portion  of  the  crowns 
by  having  the  nuts  on  the  bar  rest  on  the  mesial  end  of  the  tubes 
which  it  enters.  As  the  nuts  of  the  upper  bar  are  turned,  the  roots 
of  the  teeth  are  made  to  move  inward  through  the  process.  For 
moving  the  teeth  bodily  outward,  the  nuts  on  the  upper  bar  are 
arranged  in  front  of  the  tubes,  while  those  on  the  lower  bar  are 
usually  placed  at  the  distal  end  of  the  tubes. 

*  Case,  American  Text  Book  of  Operative  Dentistry,  1897,  p.  690. 


CHAPTER  XVin 


PROGNATHISM 


Prognathism  is  a  prominent  condition  of  the  jaws.  The  word,  as 
generally  used  in  Orthodontia,  refers  to  prominence  of  the  lower 
jaw.  Prognathism  may  result  from  inherited,  acquired,  or  local 
causes. 

In  cases  of  marked  prognathism,  the  lower  incisors  close  more  or 
less  in  front  of  the  upper  ones.  The  natural  or  anatomical  angle  of 
the  jaw  at  the  junction  of  the  body  and  ramus,  as  seen  in  the  adult, 
is  changed,  so  that  the  lower  edge  of  the  bone  from  the  symphysis  to 
its  articulation  forms  more  nearly  a  plane. 

In  less  marked  cases,  the  angle  of  the  jaw  is  more  apparent,  and 
the  lower  incisors  may  close  against  the  incisive  edge  of  the  upper 
incisors,  or  they  may  close  back  of  them  in  approximately  a  nor- 
mal position,  with  the  jaw  prominent  and  the  lower  teeth  and  pro- 
cess tipping  inward.  The  lower  incisors  may  close  back  of  the  upper 
ones,  but  with  the  anterior  upper  teeth  projecting  outward.  Or, 
again,  the  point  of  the  chin  may  lack  fulness,  the  alveolar  process 
and  teeth  being  crowded  forward. 

Fig.  375  illustrates  an  excessively  prognathous  jaw,*  in  the  case  of 
Mr.  S.,  aged  twenty-two  years.     The  upper  incisors  had  receded 

Fig.  379. 


considerably  from  a  normal  contour,  and  were  first  miovimI  bodily 
outward   with  an   appliance  as  illustrated  in   Fig.   370.      After  six 


♦Jackson,  Dental  Cosmos,  1890,  p.  879. 


824 


REDUCTION   OF  PROGNATHISM 


325 


months'  treatment,  tlie  upper  arch  and  t^eth  had  assumed  the  posi- 
tion seen  in  Fig.  379. 

Owing  to  the  mature  age  of  the  patient,  it  was  not  advisable  to 
depend  solely  on  tlie  pressure  of  a  chin-cap  and  cross-bar  for  cor- 
recting the  deformity  of  the  lower  jaw  by  changing  the  angle  causing 
absorption  in  the  glenoid  fossa',  or  by  bending  the  neck  of  tlie 
condyles,  as  is  common  with  young  patients.  It  was  determined  to 
gain  as  much  movement  as  possible  with  the  chin-cap,  and  to 
extract  the  first  lower  molars,  which  were  pulpless  at  the  outset, 
and  then  to  move  the  lower  incisors,  cuspids,  and  bicuspids  back- 
ward in  the  circle  of  the  arch.  The  latter  was  accomplished  with  a 
device  attached  to  a  chin-cap,  as  seen  in  Fig.  380.  The  apparatus 
was  constructed  bv  first  swaging  with  accurate  dies  a  chin-cap  of 


Fig.  380. 


plate-metal.     Over  the  prominent   part    of  the   cap  was  hinged  a 
double  cross-bar.     (See  Chin-Cap,  page  100.) 

The  appliance  for  retracting  the  lower  teeth  was  made  by  first 
shaping  a  spring-wire,  about  No.  16  gauge,  to  cross,  near  the  gum, 
the  labial  side  of  the  teeth  to  be  moved.  It  was  bent  into  the  circle 
it  was  desired  tlie  teeth  should  assume,  extending  back  on  either 
side  of  the  arcli,  and  bent  to  })ass  through  the  space  caused  by  the 
extraction  to  the  inner  side,  where  the  ends  were  shaped  to  extend 
forward  again,  following  the  lingual  curve  of  the  teeth  to  act  as 
springs,  each  passing  the  other  at  the  median  line.  Each  of  the 
springs  was  united  and  strengthened  by  a  bar  of  spring-wire,  which 
w^as  curved  upward  and  made  to  extend  over  the  arch  at  the  junc- 
tion of  two  of  the  teeth  and  soldered.  To  the  front  part  of  the  crib 
arrangement  were  soldered  two  posts,  made  by  shaping  a  secondary 
spring  to  pass  in  front  of  the  teeth,  giving  additional  strength  to  the 


326  PROGNATHISM 

anterior  part,  and  extending  near  the  corner  of  the  mouth  on  either 
side.  There  it  was  bent  into  loops  with  the  ends  projecting  down- 
ward, passing  over  the  lower  lip,  to  be  inserted  into  perpendicular 
tubes  which  were  soldered  to  the  outer  surface  of  the  chin-cap,  as 
seen  in  the  figure. 

It  is  found  from  experience  that  forcible  retraction  of  six  or  more 
of  the  anterior  teeth,  either  in  the  upper  or  lower  arch,  by  means 
of  a  curved  bar  of  metal  on  the  labial  side,  will  cause  some  of  the 
teeth  to  crimp ;  i.e.,  the  edge  of  one  will  pass  over  the  edge  of  the 
adjoining  one.  The  crimping  is  prevented  by  moving  the  teeth 
slowly  or  by  applying  slight  pressure  to  the  lingual  side  of  those 
that  are  inclined  to  be  forced  out  of  the  circle.  In  this  instance  the 
lingual  springs  connected  with  the  crib  arrangement  described,  dis- 
tributed the  pressure  required. 

In  adjusting  the  combined  apparatus  (Fig.  381),  the  chin-cap  was 
first  placed  in  position.  The  crib  passed  over  the  teeth,  and  the 
posts  were  pressed  into  the  tubes  deeply  enough  to  have  the  appli- 
ance rest  near  the  gum.  When  the  posts  move  too  easily  in  the 
tubes,  they  should  be  crooked  slightly  near  the  ends. 

It  is  obvious  that  properly  directed  traction  on  the  chin-cap  would 
press  the  crib  backward,  carrying  all  of  the  enclosed  incisors,  cuspids^, 
and  bicuspids  bodily  towards  the  second  molars,  which  were  finally 
almost  touched  by  the  bicuspids.  It  will  be  noticed  that  the  arch  of 
the  lower  oral  teeth  was  maintained  while  in  transit,  and  the  molars 
were  in  nowise  disturbed.  The  apparatus  was  worn  continuously 
for  six  months.  The  resulting  improvement  in  the  relationship  of 
the  teeth  is  shown  in  Fig.  382. 

For  retaining,  an  appliance  was  inserted  in  the  lower  arch,  made 
with  a  lingual  base-wire  and  anchored  with  spring-clasp  attachments 
to  the  molars.  A  semicircular  spring-wire  with  two  U-sliaped  loops 
was  formed  to  the  labial  side  of  the  teeth  near  the  gum,  with  the 
loops  opposite  the  bicuspids,  the  ends  of  the  wire  being  bent  to  pass 
through  the  space,  one  on  either  side,  and  soldered  to  the  base- 
wire.  In  addition  to  the  retaining  device,  the  chin-cap  with  the 
crib  arrangement  described  was  applied  regularly  at  night  for  over 
two  years. 

In  1878  Dr.  George  S.  i\ll;ui  j-ccoiiiiiicnded  a  chin-cap  that  has 
proved  of  great  service  to  tlie  profession  for  the  reduction  of  prog- 
nathism.    It  has  two  arms  of  wire  soldered  to  the  front  of  the  cap, 


Fig.  381. 


REDUCTION   OF  PROGNATHISM 


327 


the  ends  of  wliich  project  backward  on  eittier  side  and  terminate  in 
hooks  for  tlio  attachment  of  elastic  bands.* 

In  constructing  a  chin-cap  for  the  reduction  of  prominence  of  the 
jaw  it  should  be  made  on  an  accurate  model  of  the  chin  to  insure 

Fig.  382. 


its  perfect  adaptation,  and  good  judgment  must  be  exercised  in  deter- 
mining its  outlines. 

Some  of  the  chin-caps  recommended  are  made  to  project  far 
back  under  the  body  of  the  jaw  towards  the  angle  on  either  side, 
the  means  of  attachment  for  causing  traction  being  placed  near  the 
distal  edge.  When  elastic  pressure  is  applied  so  far  back  near  the 
angle  of  the  jaw,  it  results  in  drawing  upward  on  the  lateral  body 
at  this  point,  and  tends  to  straighten  or  cause  the  angle  to  become 
more  obtuse  ratlier  than 

,  •      1      •      J  ^  Fig.  383. 

more  acute,  as  is  desired. 
The  chin-cap  should  be 
made  to  project  suffi- 
ciently under  the  jaw, 
extending  well  back  on 
either  side,  to  equalize  the 
bearing  and  to  keep  the 
appliance  from  twisting 
out  of  place  without 
causing  excessive  pressure 
on  those  parts ;  but  the 
force  should  always  be  applied  at  the  median  line  a  little  above  the 
point  of  the  chin,  especially  in  the  treatment  of  prognathism.  The 
lines  of  force  required  are  shown  in  Fig.  383,  a,  b. 


Allen,  Trans.  Odontological  Society,  1878. 


328  PROGNATHISM 

To  obtain  the  best  results  the  chin-cap  should  be  applied  rather 
early  in  life,  before  the  bone  has  become  fully  developed.  This  is 
especially  necessary  when  the  deformity  is  inherited.  If  the  chin- 
cap  is  applied  when  the  deformity  is  first  apparent,  there  is  usually  a 
quick  response  to  the  pressure.  In  these  cases  the  chin-cap  is 
required  to  be  worn  only  at  night  and  a  few  hours  during  the  day. 
The  body  of  the  jaw  is  elongated  for  the  eruption  and  accommoda- 
tion of  the  molar  teeth  by  absorption  of  the  mesial  surface  of  the 
rami  and  a  corresponding  deposit  of  bone  on  its  distal  surface. 
While  this  progressive  anterior  development  of  the  jaw  is  taking 
place  for  the  accommodation  of  the  erupting  teeth  it  generally  requires 
but  a  comparatively  slight,  though  persistent,  force  to  change  the 
angle. 

It  is  thought  by  some  authors  that  the  angle  of  the  jaw  is  not 
materially  changed  by  external  force,  but  that  when  recession  of  the 
jaw  is  brought  about  it  is  accomplished  by  forcing  the  condyles 
backward  in  the  glenoid  fossae,  causing  absorption  of  the  bone  in 
the  distal  part. 

Distinct  changes  at  the  angle  of  the  jaw  from  external  force  can- 
not be  depended  upon  after  the  twelfth  or  fourteenth  year.  Later 
in  life  the  bones  become  more  dense,  and  only  the  most  persistent 
application  of  the  chin-cap  will  be  of  service.  Likewise  there  is 
more  soreness  and  discomfort,  and  if  there  is  a  beard  it  usually 
proves  troublesome.  The  continued  pressure  on  the  chin  interferes 
with  the  growth  of  the  hair,  causing  congestion,  which  results  in  fol- 
liculitis. This  condition  can  be  met  by  medication,  padding  the  cap 
with  soft  materials, — chamois,  cottonoid,  or  linen, — removing  the 
apparatus  frequently  and  keeping  the  chin  closely  shaven. 

The  physiological  law  (see  "The  Application  of  Force,"  p.  117), 
that  continuous  pressure  on  any  part  of  the  body  will  cause  absorp- 
tion, while  pressure  alternating  with  rest  will  cause  a  building-up,  is 
fully  as  evident  in  the  use  of  the  chin-cap  as  in  the  regulation  of  the 
teeth.  When  the  bony  tissues  are  dense  the  application  of  the  chin- 
cap  at  night  only,  say  eight  hours,  and  a  rest  during  the  day  will 
generally  avail  little,  for  during  the  sixteen  hours,  in  a  healthy  person, 
nature  will  have  had  sufficient  time  to  repair  any  injury  of  the  bone 
that  may  have  been  caused  by  the  continuous  strain  of  the  chin-cap 
during  the  night.  For  this  reason,  with  the  adult,  the  chin-cap  should 
be  worn  continuously,  or  at  least  eighteen  or  twenty  hours  out  of  the 


Fig.  384. 


Fig.  385. 


Fig.  386. 


Fig.  387. 


REDUCTION  OF  PROGNATHISM  329 

twenty-four.  If  force  is  applied  but  a  few  hours  during  the  day,  and 
nature  is  able  to  resist  it,  the  j^art  of  the  jaw  put  under  strain  becomes 
more  developed  and  its  walls  are  thickened.  When  the  chin-cap  is 
used  for  a  considerable  length  of  time  for  the  correction  of  obstinate 
cases  of  prognathism  or  lack  of  anterior  occlusion,  the  lower  jaw  in 
some  cases,  especially  with  tlie  adult,  becomes  broadened  in  the  region 
of  the  angle,  and  the  bone  is  thickened  to  a  disagreeable  and  notice- 
able extent.  When  this  prominence  is  being  brought  about  it  can  be 
prevented  by  extending  a  round  or  flat  metal  spring  backward  from 
the  sides  of  the  chin-cap  supporting  a  pad  to  rest  overtlie  i)rominent 
parts,  to  press  inward  as  force  is  applied  at  the  point  of  the  chin. 

Again,  when  tlie  bones  are  dense,  a  cross-bar  for  reducing  upper 
anterior  protrusion,  when  used  alone  and  only  at  night  is  seldom 
efficacious.  A  regulating  device  should  be  worn  continuously  in  the 
mouth  and  the  cross-bar  used  as  supplemental  force,  or  the  cross-bar 
used  continuously.     In  other  cases  a  cross-bar  is  used  only  at  night. 

In  moderate  prognathism  with  the  adult,  not  infrequently  a  satis- 
factory improvement  in  the  contour  of  the  features  and  occlusion  of 
the  teeth  can  be  made  by  moving  the  upper  front  teeth  and  process 
outward  and  the  lower  front  teeth  inward,  harmonizing  the  mesio- 
distal  relation  of  the  jaws.  This  treatment  with  the  following  ap- 
paratus was  employed  in  1897  in  the  case  of  Mr.  A.,  aged  eighteen 
years.     The  method  was  used  in  a  similar  case  in  1889. 

Fig.  384  shows  an  outline  of  the  features  before  regulation.  The 
upper  incisors  were  moved  bodily  outward,  the  apparatus  being 
arranged  to  open  the  bite.  An  appliance  was  made  for  moving  the 
lower  incisors  and  cuspids  inward,  the  loss  of  the  first  bicuspids 
leaving  space  (Fig.  385).  For  anchorage,  a  swaged  metal-cap  with 
a  wire  staple  or  eyelet  soldered^  to  the  buccal  slirface  was  cemented 
to  the  molars  and  second  bicuspid  on  each  side  of  the  arch.  A 
similar  metal  cap  was  cemented  to  the  incisors,  on  the  front  of  which 
was  attached  a  wire  loop  projecting  upward  and  forward  to  support 
a  cross-bar.  A  labio-buccal  spring.  No.  14  gauge,  was  applied.  It 
was  provided  with  a  U-shaped  loop  on  either  side  pointing  down- 
ward opposite  the  first  molars,  as  shown  at  «,  a,  and  the  ends  were 
shaped  to  hook  into  the  eyelets  on  the  buccal  side  of  the  caps.  The 
labial  part  of  the  spring  was  retained  by  passing  below  the  wire  pro- 
jection of  the  cap  on  the  incisors.  Pressure  was  caused  by  closing 
the  loops  of  the  spring  slightly  from  time  to  time. 


330  PROGNATHISM 

To  supply  the  main  force,  an  external  apparatus,  made  as  described 
on  page  97,  with  a  cranial-cap  and  a  double  cross-bar  pivoted  in 
the  centre,  similar  to  a  swing-tree,  was  applied  (Fig.  386).  A 
curved  arm  of  rigid  wire,  No.  8  gauge,  was  shaped  to  extend  over 
the  lower  lip  (the  bar  can  be  left  straight  if  desired),  with  one  end 
formed  into  a  head  to  catch  into  the  loop  on  the  cap  over  the 
incisors,  and  the  other  end  soldered  firmly  to  the  cross-bar. 

The  curved  wire  extending  over  the  lip  in  this  manner  exerted 
direct  inward  force  on  the  lower  teeth  when  traction  was  applied 
from  the  occipital  anchorage.  The  operator  should  bear  in  mind 
that  the  articulation  of  the  jaw  in  the  glenoid  fossa?  is  a  little  in 
front  of  the  middle  third  of  the  ear  from  above  downward.  The 
elastics  extending  from  the  cranial-cap  to  the  bar  should  not  draw 
downward  or  upward  too  much,  but  their  traction  should  be  such 
as  to  balance  the  jaw  upward  slightly,  so  that  the  lower  molars  and 
bicuspids  will  rest  against  the  upper  ones.  If  there  is  a  tendency  for 
the  incisor  teeth  to  elevate,  a  thickened  palatine  plate  similar  to  Fig. 
337  may  be  employed  ;  the  bite  can  be  opened  when  necessary  by 
extending  the  plate  over  the  molars.  In  the  case  described  the 
cross-bar  was  worn  regularly  at  night  and  as  many  hours  as  prac- 
ticable during  the  day,  shortening  the  straps  for  causing  additional 
force  by  rebuckling  as  required.  Fig.  387  illustrates  the  contour  of 
the  features  after  correction. 

With  the  adult,  Avhen  the  alveolar  process  is  dense,  it  is  sometimes 
injudicious  to  apply  the  excessive  force  required  for  moving  the  four 
incisors  and  the  cuspids  inward  at  one  time.  Instead  of  this,  first 
move  the  teeth  on  one  side  of  the  median  line  and  then  those  on 
the  other.  In  such  a  case  a  metal  cap  with  a  socket  in  the  centre 
should  be  cemented  to  only  the  incisors  and  cuspid  on  one  side  of 
the  arch.  After  they  are  moved  to  position,  the  teeth  on  the  oppo- 
site side  can  be  moved  in  the  same  manner. 

When  supplemental  force  is  required  in  moving  outward  the 
upper  teeth,  while  at  the  same  time  the  lower  teeth  are  being  moved 
inward,  an  equalizing  device,  as  seen  in  Fig.  388,  can  be  applied. 
It  is  made  with  a  chin-cap  and  standards  of  wire  and  tubes  sup- 
ported by  a  cranial-cap,  as  described  on  page  255.  An  infralabial 
bar  of  stiff  wire,  as  illustrated  in  Fig.  214,  is  adjusted  to  cause 
pressure  on  the  lower  teetli.  Force  is  caused  by  i>assing  elastic 
ligatures  from  the  knobs  on  the  bar  to  the  adjustable  knobs  on  the 


Fk;.  3SS. 


Fig.  3S9. 


Fig.  390. 


Fig.  391. 


Fig.  392. 


REDUCTION  OF  PROGNATHISM  331 

wire  standards.  A  supralabial  bar  for  moving  outward  the  upper 
teeth  (Fig.  374)  is  made  of  wire  witli  large  loops  projecting  ui)ward 
just  in  front  of  the  standards.  Tlie  bar  is  attached  to  the  teeth  by 
a  wire  (6)  curved  to  extend  from  it  over  tlie  lip,  with  the  ends  shaped 
to  hook  into  an  eyelet  or  bent  at  right  angles  to  hook  into  a  tube; 
or  the  attachment  can  be  made  in  any  other  manner  desirable.  The 
ends  of  the  bar  are  provided  with  hooks  to  engage  with  adjustable 
knobs  on  the  tubes  of  the  standards.  Force  is  got  by  opening  the 
loops  gradually  by  bending.  This  ajiparatus  can  be  adjusted  for 
forcing  outward  the  teeth  in  a  receding  lower  jaw,  at  the  same  time 
reducing  the  prominence  of  the  upper  jaw  by  reversing  the  arms 
and  their  attachment.  In  equalizing  the  jaws  when  moderate  force 
is  recjuired,  the  device,  with  slight  modification,  may  be  used  without 
the  chin-cap. 

For  moving  cuspids  inward  or  backward  by  means  of  external 
anchorage,  see  Fig.  439  ;  for  moving  bicuspids  backward  in  the  line 
of  the  arch,  see  Figs.  470-475. 

When  the  incisor  teeth  occlude  on  their  edges,  their  position 
should  be  corrected,  causing  the  upper  incisors  to  close  in  front  of 
the  lower  ones.  If  not  corrected,  the  edges  of  these  teeth  and  of 
others  in  the  arch  become  worn,  disfiguring  them  and  allowing  the 
jaws  to  come  closer  together.  The  temporo-maxillary  articulation 
of  the  lower  jaw  is  considerably  above  the  line  of  the  occlusion  of 
the  teeth,  and  as  the  teeth  become  worn,  the  jaw  is  gradually 
permitted  to  project  farther  forward,  causing  the  lower  incisors  to 
close  in  front  of  the  upper  ones. 

Fig.  389  illustrates  the  features  of  Miss  S.,  aged  forty-nine  years. 
The  early  regulation  of  the  teeth  had  been  neglected,  and  an  extreme 
prognathous  condition  resulted  in  the  manner  described. 

The  bite  was  opened,  and  the  lower  teeth  moved  inward  to  close 
back  of  the  upper  ones  with  an  appliance  similar  to  that  shown  in 
Fig.  210.  For  opening  the  bite,  bars  of  metal  were  attached  to  the 
spring-clasps  over  the  anchorage  portion  (Fig.  188).  After  the 
incisors  were  moved  inward,  pressure  was  applied  with  a  chin-cap  to 
force  the  jaws  together  and  adjust  the  occlusion.  The  change  in 
the  line  of  the  features  is  shown  in  Fig.  390. 

Hereditary  prominence  of  the  lower  jaw  is  usually  accompanied  with 
nasal  stenosis,  enlarged  tonsils,  and  more  or  less  arrest  of  development 
of  the  upper  maxilla.     Examples  are  seen  in  Figs.  381,  391,  and  393. 


332  PROGNATHISM 

Fig.  391  shows  the  contour  of  the  features  of  Mr.  J.,  aged  twenty- 
one  years,  a  case  of  heredity.  His  sister  and  one  of  their  parents 
had  a  similar  deformity.  When  the  patient  was  first  examined,  the 
lower  incisors  were  beginning  to  close  in  front  of  the  upper  ones. 
The  tonsils  were  found  to  be  enlarged,  and  there  was  partial  nasal 
stenosis.  To  improve  the  nasal  breathing  the  obstructions  were 
removed  by  a  rhinologist.  A  chin-cap  was  then  applied,  as  shown 
in  Fig.  392,  for  forcing  the  jaw  backward  into  its  relative  position, 
and  the  patient  was  directed  to  wear  it  continuously  or  regularly  at 
night  and  as  many  hours  as  possible  during  the  day.  The  sister's 
deformity  was  also  corrected. 

The  serious  conditions  that  result  from  neglect  of  early  treatment 
of  prognathism  should  warn  the  operator  to  watch  carefully  any 
suspected  case  and  advise  the  patient. 

The  history  of  an  interesting  case  of  progressive  prognathism  is 
described  on  page  202. 

Fig.  393  illustrates  a  case  of  extreme  protrusion  of  the  lower  jaw. 
Miss  H.,  aged  twenty-four  years.  There  was  no  apparent  angle  of 
the  jaw  and  only  slight  occlusion  of  the  back  teeth.  The  lower 
lip  projected  nearly  as  far  as  the  point  of  the  nose.  The  upper 
incisive  region  was  poorly  developed,  and  there  was  a  marked  degree 
of  nasal  stenosis.  Owing  to  the  age  and  the  extreme  protrusion  of 
the  jaw,  it  was  decided  that  the  ordinary  method  of  procedure  for  its 
correction  would  not  be  effective,  and  that  a  surgical  operation 
should  be  resorted  to, — the  removal  of  a  section  of  bone  frem  the 
body  of  the  jaw  and  alveolar  process  in  the  bicuspid  region  on  each 
side  of  the  arch.* 

When  in  cases  of  extreme  prognathism  in  the  adult  it  is  not 
considered  advisable  to  change  the  position  of  the  teeth  in  the 
process,  the  contour  of  the  features  can  in  some  instances  be  im- 
proved by  the  use  of  a  plate  in  the  upper  arch,  having  artificial 
teeth  arranged  outside  of  the  line  of  the  natural  ones.  Several 
methods  have  been  recommended  by  different  practitioners.  Dr.  J. 
H.  Meyer  cites  a  casef  in  which  he  swaged  a  platinum  plate  to  pass 


*  Hullihen,  American  Journal  of  Dental  Science,  1849,  p.  157  ;  Ottoleiigui, 
Denial  Cosmos,  1897,  p.  143  ;  Whipple,  Dental  Cosmos,  1898,  p.  552  ;  Angle, 
Dental  Cosmos,  1898,  p.  635. 

f  Meyer,  Dental  Cosmos,  1884,  p.  669. 


Fig.  394. 


Fig.  395. 


Fig.  39fi. 


REDUCTION   OF   PROGNATHISM  333 

over  the  natural  incisors  and  cuspids,  supported  witli  vulcanite,  pass- 
ing over  the  palatine  portion  of  the  arch.  To  the  platinum  on  the 
labial  side  were  soldered  plate  teeth  in  position  to  articulate  properly 
with  the  teeth  of  the  lower  arch.  The  appearance  and  outline  of 
the  features  were  noticeably  improved. 

Not  infrequently  cases  are  presented  where  it  is  desirable  to 
improve  the  general  occlusion  of  the  teeth,  the  lower  arch  being 
broad  and  prominent,  the  upper  arch  narrow  and  insufficiently 
developed,  with  perhaps  one  or  more  teeth  absent,  permitting  the 
teeth  of  the  upper  arcli  to  close  inside  of  the  circle  of  the  lower 
ones,  giving  too  close  a  bite  and  bringing  about  prognathism.  For 
this  condition  a  palatine  plate  may  be  made,  passing  over  the 
upper  teeth,  with  a  ledge  on  the  outer  surface,  or  artificial  teeth 
attached  when  necessary,  to  form  an  occlusion  with  the  lower  teeth. 
This  procedure  was  recommended  in  the  case  of  Master  K.,  aged 
thirteen  years.  These  conditions  may  also  occasionally  be  im- 
proved by  the  application  of  a  plate  supported  by  the  lower  teeth, 
made  to  project  inward  from  the  teeth  sufficiently  to  form  a  grinding 
surface  for  occlusion  with  the  teeth  of  the  upper  arch,  but  not  pro- 
jecting so  far  as  to  irritate  or  interfere  with  the  action  of  the  tongue, 
the  inner  edges  of  the  plate  being  well  rounded  and  smooth.  The 
plate  can  be  made  entirely  of  vulcanite,  or  of  metal  by  fitting  a 
swaged  portion  accurately  over  the  grinding  surface  of  the  lower 
teeth,  making  it  project  lingually  to  form  a  ledge  for  the  articulation 
with  the  upper  ones.  When  there  is  sufficient  room,  thin  porcelain 
teeth  can  be  attached  to  the  swaged  portion  of  the  cap  on  either 
side,  setting  the  teeth  in  natural  position,  or  having  them  reversed 
and  attached  with  solder  or  vulcanite. 

The  opposite  condition  is  sometimes  presented.  In  the  case  of 
Master  S.,  aged  seven  years,  the  upper  arch  was  very  large,  with  no 
spaces  between  the  teeth ;  the  lower  arch  small,  and  the  front  teeth 
biting  against  the  gum,  none  of  the  teeth  occluding  with  those  of 
the  upper  arch.  An  upper  palatine  vulcanite  plate  having  a  ledge 
for  occlusion  with  the  lower  teeth  was  inserted  favoring  natural 
mastication ;  at  the  same  time  a  device  was  applied  in  the  lower 
arch  for  its  expansion,  (See  description  in  connection  with  Figs. 
88-91.) 

When  the  nose  is  large  and  the  region  of  the  upper  lip  is  de- 
pressed, with  a  prognathous   lower  jaw,  it  is   usually  advisable  to 


334  PROGNATHISM 

move  outward  the  upper  incisors  and  process  to  improve  the  facial 
line. 

Fig.  394  illustrates  the  case  of  Master  S.,  aged  fourteen  years. 
During  the  eruption  of  the  permanent  teeth  the  upper  incisors  were 
permitted  to  close  back  of  the  lower  ones,  which  encouraged  the 
lower  jaw  and  teeth  to  take  a  prominent  position  and  depress  the 
anterior  part  of  the  upper  arch.  As  is  usually  the  case  when  this 
condition  is  permitted  to  continue,  the  anterior  development  of  the 
lower  jaw  had  been  encouraged  by  the  abnormal  occlusion  of  the 
teeth  to  such  an  extent  that  it  was  not  only  necessary  to  move  the 
upper  incisors  outward  to  close  in  front  of  the  lower  ones  (Fig.  395), 
but  to  apply  a  chin-cap  to  cause  inward  pressure  on  the  lower  jaw, 
and  at  the  same  time  to  force  it  upward,  in  order  to  cause  the  lower 
incisors  to  occlude  well  back  of  the  upper  ones  and  improve  the 
profile  (Fig.  396). 

Attention  has  already  been  called  in  this  chapter  to  the  advantage 
of  early  treatment  for  the  correction  of  prognathous  conditions, 
especially  when  the  deformity  is  inherited.  When  brought  about  by 
an  acquired  or  local  cause  it  should  first  be  removed  and  the  correc- 
tion proceeded  with  in  the  usual  manner. 

Fig.  397  illustrates  the  case  of  a  child  aged  five  years,  with  the 
deciduous  lower  incisors  and  cuspids  closing  in  front  of  the  line  of 

Fig.  397. 


the  upper  ones.  The  irregularity  was  inherited,  both  parents  having 
a  prominent  lower  jaw.  On  examination  the  child  was  found  to  be 
suffering  with  both  faucial  and  nasal  obstructions.  The  parents  were 
directed  to  have  the  obstructions  removed  by  the  rhinologist,  but 
these  directions  were  not  carried  out. 

When  the  child  was  ten  years  of  age  the  writer  was  again  called 
upon  to  examine  the  case.     The  permanent  teeth  had  erupted,  with 


Fk;.  398. 


REDUCTION   OF  UNILATERAL   PROGNATHISM  335 

the  lower  incisors  closing  considerably  in  front  of  the  upper  ones 
and  with  the  nasal  and  faucial  conditions  aggravated.  The  parents 
were  again  advised  to  have  the  obstructions  removed  immediately. 
The  operation  was  performed,  improving  the  nasal  breathing,  as  was 
anticipated.  The  upper  incisors  were  then  moved  outward,  after 
wliich  a  chin-cap,  as  seen  in  Fig.  398,  was  applied  and  worn  regu- 
larly at  night  and  a  few  hours  during  the  day.  In  tliis  case,  as  is 
common  with  young  patients,  the  jaw  yielded  to  the  force  and  took 
a  good  position,  but  the  use  of  the  chin-cap  was  continued  with 
light  pressure  for  over  a  year,  the  case  being  examined  carefully 
from  time  to  time  to  anticipate  any  undesirable  change.  The  con- 
tinued use  of  the  chin-cap  is  often  required  for  several  years. 

In  prognathous  conditions  it  is  sometimes  an  advantage  to  use  an 
inclined  plane  for  their  correction.  The  pressure  in  occlusion  settles 
the  incisors  into  their  sockets,  while  the  relief  from  pressure  on  the 
teeth  in  the  sides  of  the  arch  permits  the  latter  to  elevate,  gradually 
bringing  them  and  the  incisors  to  the  same  plane  of  occlusion.  The 
inclined  plane  for  this  purpose,  however,  should  not  be  employed 
except  where  the  incisors  are  considerably  elevated.  A  unique  case 
of  this  character  is  seen  in  Figs.  184-186. 

Unilateral  Prognathism. — Unilateral  prognathism  of  the  lower 
jaw  is  frequently  met  with.  It  may  result  from  a  local  or  a  con- 
stitutional cause,  as  from  the  injudicious  extraction  of  one  or  more 
of  the  permanent  teeth  on  one  side  of  the  upper  arch,  from  an 
excessive  development  of  the  lower  arch,  or  from  the  improper 
development  of  the  upper  arch ;  the  two  latter  forms  result  from 
inherited  or  acquired  causes.  It  is  usually  progressive,  becoming 
more  defined  as  the  patient  grows  older.  When  the  upper  arch  is 
less  fully  developed  on  one  side  than  the  lower,  this  condition 
permits  the  teeth  to  close  inside  of  the  line  of  the  lower  arch, 
destroying  the  occlusion  on  that  side.  The  teeth  become  extruded, 
gradually  forcing  the  lower  jaw  forward  and  to  one  side,  and  wear- 
ing away  the  edge  of  some  of  the  mcisors,  but  usually  leaving  a 
reasonably  good  occlusion  of  the  teeth  on  the  opposite  side  of  the 
arch.  This  results  in  an  extreme  deformity  of  the  features.  Fig.  107 
illustrates  a  marked  case.  For  its  correction  it  is  usually  necessary 
to  expand  the  upper  arch  (see  Unilateral  Expansion,  page  138)  or 
to  contract  the  lower  arch,  and  in  some  instances  to  extract  one  or 
more  of  the  lower  teeth  and  apply  a  chin-cap  in  the  manner  described. 


CHAPTER  XIX 
RECEDING    LOWER    JAW 

Recession  of  the  lower  jaw  may  result  from  heredity,  from  an 
arrest  of  development,  or  from  the  injudicious  removal  of  the  lower 
permanent  teeth,  interfering  with  its  anterior  growth. 

An  apparent  recession  of  the  lower  jaw  may  be  caused  by  abnor- 
mal prominence  of  the  upper  incisors  and  alveolar  process  (Fig.  399). 
In  these  cases,  the  line  of  the  features  can  generally  be  improved  by 
moving  inward  the  upper  teeth  and  process. 

If,  from  the  contour  of  the  features,  or  the  size  and  prominence 
of  the  nose,  the  lessening  of  the  fulness  in  the  region  of  the  upper 
lip  is  not  desirable,  the  facial  line  and  the  occlusion  can  sometimes 
be  improved  by  the  anterior  expansion  of  the  lower  arch ;  moving 
outward  the  lower  front  teeth  and  process  by  an  appliance  similar 
to  Fig.  134  or  137.  In  some  instances  a  slight  and  gradual  broad- 
ening of  the  upper  arch  laterally  will  be  sufficient  to  move  the  lower 
arch  forward  as  a  result  of  improved  occlusion. 

Fig.  400  illustrates  the  features  of  Miss  F.,  aged  eleven  years ;  a 
marked  case  of  receding  lower  jaw,  with  the  upper  arch  too  promi- 
nent. The  patient  suffered  from  mouth-breathing,  induced  by  nasal 
stenosis.  The  first  upper  bicuspids  were  extracted,  the  incisors  and 
cuspids,  with  the  process,  moved  inward,  and  the  arch  broadened. 
This  procedure  caused  the  lower  jaw  to  bite  farther  forward,  im- 
proving the  facial  line,  as  seen  in  Fig.  401. 

An  interesting  case  of  hereditary  recession  of  the  jaw  is  shown 
in  Fig.  402,  Miss  C,  aged  twenty -three  years.  The  upper  incisors 
vk^ere  prominent,  irregular,  and  a  little  to  one  side  of  the  median 
line.  To  give  space  for  their  correction  and  to  reduce  the  promi- 
nence, a  first  upper  bicuspid  was  extracted,  and  a  device  was 
inserted  which  at  the  same  time  encouraged  the  lower  jaw  to  bite 
farther  forward.  An  apjjliance  was  also  inserted  in  the  lower  arch 
for  its  anterior  expansion. 

Equalizi.ng  the  Jaws. — Many  methods  have  been  employed  for 
harmonizing  the  antero-posterior  relationship  of  the  jaws  when 
unequal  in  prominence  or  size,  for  improving  the  facial  contour  and 

336 


F:g.  399. 


Vu;.  400. 


Fig.  401. 


Fig.  402. 


EQUALIZING  THE  JAWS  337 

the  occlusion,  tlie  eitect  being  to  force  inward  one  arch  and  outward 
the  other.  Suitable  apparatus  is  described.  For  this  purpose 
rubber  bands  have  been  used,  attached  one  on  either  side  of  the 
arches,  extending  from  the  anterior  third  of  a  prominent  upper  arch 
to  the  distal  part  of  a  receding  lower  arch,  or  vice  versa. 

From  time  to  time  for  many  years,  members  of  the  profession 
have  employed  and  descrilDod  elastic  rubber  extending  from  one  arch 
to  the  other,  ligating  the  rubber  directly  to  the  teeth,  or  fastening  it 
to  collars,  but  without  any  general  systematic  method  in  its  appli- 
cation. 

More  recently  the  especial  advantages  of  elastic  rubber  for  these 
purposes  has  been  pointed  out,  notably  by  Drs.  Case"*",  Angle, f  and 
Baker.  I 

The  objection  to  its  use  has  been  the  displacement  of  the  teeth 
used  for  anchorage,  crimping  them  or  drawing  some  of  them  out 
of  their  sockets.  The  principle  will  be  better  understood  when 
we  consider  that  in  prominence  of  the  upper  arch  the  incisors 
and  those  of  the  lower  arch  are  naturally  more  or  less  extruded  with 
the  process,  being  elevated  beyond  their  normal  plane.  The  con- 
stant tension  of  rubber  bands  for  relieving  the  upper  prominence, 
owing  to  its  angle,  drawing  downward  and  backward  on  these  teeth, 
tends  to  elevate  them  more,  and  at  the  same  time  it  elevates  the 
teeth  used  for  anchorage  in  the  distal  part  of  the  lower  arch. 

When  used  for  correcting  a  receding  upper  jaw  and  prominent 
lower  jaw,  the  effect  is  about  the  same,  in  some  instances  drawing 
upward  on  the  anterier  lower  teeth,  in  others  tipping  the  upper  jaw 
forward  and  upward  and  elevating  the  molars  used  for  anchorage  to 
such  an  extent  as  to  cause  lack  of  anterior  occlusion.  Rubber  bands 
attached  to  the  distal  part  of  the  upper  arch  by  continuous  apparatus 
passing  over  the  teeth,  and  to  the  anterior  third  of  the  lower  arch  by 
continuous  apparatus  were  used  for  Mr.  D.  in  1889.  The  anchorage 
teeth  were  disturbed  in  their  sockets  before  the  jaws  were  equalized, 
and  another  form  of  apparatus  was  necessarily  devised. 

In  the  use  of  rubber  bands,  the  anchorage  to  the  teeth  is  to  be 


*  Case,   Trans.   World's   Columbian  Dental  Congress,    1893,    vol.    ii.    p.    731  ; 
Dental  Cosmos,  1904,  p.  345. 

t  Angle,  Treatment  of  Malocclusion  of  the  Teeth.  1900,  p.  284. 
I  Baker,  International  Dental  Journal,  1904,  p.  344. 

22 


338  RECEDING   LOWER  JAW 

made  in  any  suitable  manner ;  but  it  is  always  necessary  to  include 
in  the  anchorage  on  each  side  at  least  three  teeth  in  each  arch; 
otherwise  the  teeth  would  gradually  be  drawn  out  of  position  by  the 
constant  force  applied,  either  elevating  or  crimping  them.  In  some 
instances  this  can  be  prevented  by  using  a  band  of  less  tension,  or 
by  forming  an  ancliorage  to  more  of  the  teeth  in  each  arch.  This 
is  done  either  by  cementing  collars  to  some  of  them  with  bars 
connecting  the  collars,  by  cementing  to  the  teeth  of  the  upper  and 
lower  arches  carefully  adjusted  spring-clasp  attachments,  or  by 
cementing  to  the  teeth  thin  metal  caps,  usually  passing  over  all 
of  the  teeth,  having  the  occlusal  planes  made  broad  and  arranged 
at  an  angle  or  incline  favoring  the  movement  towards  a  normal 
occlusion.  When  the  upper  or  lower  incisors  are  extruded  or 
rest  on  a  higher  plane  than  the  molars  and  bicuspids,  elevating  the 
planes  and  opening  the  bite  is  sometimes  necessary,  to  permit  the 
incisors  to  pass  from  a  labial  to  a  lingual  occlusion,  or  the  reverse. 
Knobs,  hooks,  or  eyelets  for  holding  the  rubber  band  or  a  metal 
spring,  should  be  located  on  the  buccal  side  near  the  occlusion  line. 
This  provision  causes  a  more  direct  tension  from  front  to  back; 
improving  the  angle,  and  thus  lessening  the  tendency  to  the  tipping 
of  the  arches. 

In  equalizing  the  jaws  the  apparatus,  to  be  most  effective,  should 
be  applied  while  the  patient  is  young,  and  the  appliance  arranged  to 
hold  the  jaws  at  the  desired  plane.  The  force  must  be  constant 
and  sufficient  to  overcome  the  natural  tension  of  the  muscles,  and 
continued  until  the  jaws  become  equalized,  either  by,  first,  bending 
the  bones  ;  second,  causing  contraction  of  one  of  the  arches  and 
anterior  development  of  the  other;  third,  the  instituting  of  a  new 
temporo-maxillary  articulation,  or,  fourth,  by  establishing  a  new 
occlusion.  The  two  former  results  are  to  be  sought  for;  they  are 
usually  attained  with  the  young  and  when  the  force  is  continued. 
The  two  latter  seldom  prove  as  satisfactory,  as  usually  while  laughing, 
or  when  the  features  are  in  repose,  the  teeth  not  resting  in  contact, 
the  lower  jaw  slides  backward  more  or  less,  marring  the  facial  line 
and  causing  an  apparent  upper  protrusion. 

In  the  following  division  of  this  chapter,  and  in  different  parts  of 
this  work,  other  methods  are  described  for  harmonizing  the  antero- 
posterior relationship  of  the  jaws. 

Jumping  the  BrrE. — Recession  of  [he.  l()vv(;r  jaw  is  caused  by  its 


JUMPING  THE    BITE  339 

failing  to  keep  pace  with  ttie  upper  jaw  in  its  anterior  development, 
often  making  the  lower  teeth  occlude  back  of  their  normal  posi- 
tion as  far  as  the  width  of  one  of  the  bicuspids ;  that  is  to  say,  the 
cusps  of  the  first  lower  bicuspids  close  back  of  the  cusps  of  the 
first  upper  bicuspids,  instead  of  in  front  of  them  as  in  normal 
occlusion  ;  while  the  lower  incisors  are  usually  elevated,  and  on  a 
considerably  higher  plane  than  the  bicuspids  and  molars. 

Afler  careful  measurement,  if  it  is  seen  that  the  anterior  expan- 
sion of  the  lower  arch  by  the  outward  movement  of  the  lower 
incisors  will  not  sufficiently  improve  the  facial  line  and  cause  a  good 
occlusion,  an  appliance  for  moving  the  lower  jaw  forward  the  width 
of  one  of  the  bicuspid  teeth  should  be  employed.  This  operation 
has  been  termed  jumping  the  bite,  and  was  first  recommended  by 
Dr.  Kingsley,  He  used  for  this  purpose  a  palatine  vulcanite  plate 
having  an  inclined  plane  located  near  the  upper  incisors,  shaped  to 
project  sharply  downward  and  backward  to  engage  with  the  lingual 
faces  of  the  lower  incisors  in  occlusion.*  By  this  the  lower  incisors 
are  sometimes  tipped  outward,  although  in  young  patients  the  prin- 
cipal change  is  the  lengthening  of  the  lower  jaw,  which  takes  place 
in  its  body  and  at  its  angles,  as  a  result  of  interstitial  growth.  This 
gradual  change  will  be  better  understood  when  we  consider  nature's 
method  of  lengthening  the  jaw,  which  naturally  takes  place  near 
the  rami  for  the  accommodation  of  the  erupting  molar  teeth. 

Aside  from  the  interstitial  growth,  there  is  an  absorption  of  the 
mesial  surface  of  the  rami,  and  a  corresponding  deposition  of  bone 
on  the  distal  part,  which  makes  apparent  the  change  in  the  shape 
of  the  jaw,  from  the  obtuse  angle  of  the  child  to  the  more  right 
angle  of  the  jaw  of  the  adult. 

The  operation  of  jumping  the  bite  or  equalizing  the  jaws,  to  be 
most  successful  in  the  way  of  lengthening  the  lower  jaw,  should  be 
undertaken  before  the  twelfth  year,  or  before  the  eruption  of  the 
second  permanent  molars.  The  appliance  should  be  worn  constantly 
for  several  months,  or  until  the  occluding  teeth  have  become  settled 
together,  and  if  need  be  until  there  is  a  normal  articulation  of  the 
condyles  of  the  jaw  in  the  glenoid  fossae,  the  second  molars  being 
fully  erupted  and  a  new  occlusion  established.  In  the  adult  the 
operation  of  jumping  the  bite  is  not  as  satisfactory,  as  the  change  in 


Kingsley's  Oral  Deformities,  p.  84. 


340 


RECEDING  LOWER  JAW 


the  form  of  the  jaw  is  not  as  readily  made.  If  the  treatment  does 
not  change  the  shape  of  the  jaw,  it  should  be  held  forward  in  its  new 
position,  being-  retained  for  an  indefinite  period,  when  gradually  a 
new  temporo-niaxillary  articulation  will  bo  established  in  the  glenoid 
fossae,  sometimes  by  the  building  on  of  bone.  The  object  of  moving 
the  jaw  forward  in  this  manner,  changing  the  bite,  is  to  improve  the 
facial  line,  and  at  the  same  time  improve  the  occlusion  of  the  molars 
and  bicuspids  as  well  as  the  incisors. 

Jumping-  the  Bite  Forward. — When  the  jaws  are  inharmonious 
in  their  mesio-distal  relations,  and  jumping  the  bite  forward  is  indi- 
cated, any  spaces  that  exist  between  the  teeth  of  the  upper  arch 
should  first  be  closed  by  moving  them  inward,  and  an  apparatus 
anchored  in  each  arch  for  the  attachment  of  small  rubber  bands 
for  causing  the  recfuired  anterior  and  posterior  traction  as  described  ; 
or  a  semicircular  spring  can  be  shaped  to  pass  in  front  of  the  incisors 
with  the  ends  anchored  in  a  palatine  vulcanite  plate  used  to  sup- 
port an  inclined  plane,  as  seen  in  Fig.  403.     The  plate  is  made  with 

Fig.  403. 


suitable  means  of  anchorage,  as  with  spring-  or  wire-clasps,  with  a 
jjrojection  of  rubber  extended  from  the  anterior  part  sloping  sharply 
downward  and  backward  for  forming  the  inclined  plane ;  it  should 
be  shaped  so  that  during  occlusion  it  will  pass  back  of  the  lower 
incisors  and  cuspids,  causing  the  lower  jaw  to  be  moved  forward  for 


JUMPING  THE   BITE   FORWARD 


341 


a  distance  usually  equal  to  the  width  of  one  of  the  bicuspid  teeth. 
The  closing  of  the  lower  incisors  against  the  inclined  plane  in  the 
manner  described  has  the  effect  of  stretching  the  lower  jaw,  en- 
couraging its  anterior  development. 

Another  form   of  apparatus    for   tliis   purpose  is   constructed  as 
seen  in  Fig.  404.     A  palatine  plate  of  vulcanite  is  well  fitted  to  the 

Fig.  404. 


upper  arch.  From  the  disto-lateral  edges  there  is  an  extension  of 
vulcanite  or  metal  passing  across  the  grinding  surface  of  the  last 
erupted  upper  molar  on  each  side.  They  should  be  shaped  in  such 
a  manner  as  to  project  downward,  forming  steep  inclined  planes, 
sloping  slightly  backward  to  engage  \vith  the  distal  grinding  surface 
of  the  last  erupted  lower  molars.  Projecting  inclined  planes  of  metal 
attached  in  the  vulcanite  are  usually  preferable.  It  is  essential  that 
the  plate  be  strongly  anchored  and  worn  constantly  for  a  consider- 
able length  of  time.  A  lingual  base-wire  (Fig.  406)  is  sometimes 
used  in  place  of  the  plate. 

In  jumping  the  bite  forward,  where  the  molars  are  sufficiently 
erupted,  a  device  for  retaining  the  lower  arch  in  position  can  be 
made  by  attaching  an  inclined  plane  directly  to  one  of  the  last  upper 
molars  on  each  side  (Fig.  405).  A  strong,  broad  collar  is  fitted  well 
to  one  of  the  molars,  and  a  suitably  shaped  piece  of  heavy  plate- 
metal  or  a  bar  for  an  inclined  plane  is  soldered  to  it.  The  incline 
should  project  downward  back  of  the  last  molar  in  the  lower  arch, 
causingr  the  teeth   to   occlude  as   desired.     The   collars  should  be 


342 


RECEDING  LOWER  JAW 


Fig.  405. 


strongly  cemented.  If  either  the  device  or  the  anchorage-teeth  be- 
come loosened  under  tlie  pressure,  an  additional  collar  should  be 
fitted  to  an  adjoining  tooth,  the  two  collars  united  with  solder  and 
cemented  firmly  to  the  teeth,  one  inclined  plane  on  each  side  of  the 
arch,  or  another  means  of  anchorage  should  be  used. 

Jumping-  the  Bite  Backward. — The  opposite  procedure  from 
jumping  the  bite  forward  is  indicated  when  the  lower  jaw  has  moved 
forward  more  than  is  natural  in  its  articulation,  the  cusps  of  the 
second  lower  bicuspids  occluding  with  or  in  front  of  the  cusps  of  the 
first  upper  bicuspids.  This  condition  is  not  unusual.  It  may  be 
brought  about  by  heredity,  enlarged  tonsils,  with  nasal  stenosis  ac- 
companying mouth-breathing,  or  by  local  causes,  as  the  improper 
eruption  of  the  upper  incisors,  they  taking 
a  position  back  of  the  lower  ones,  forcing 
the  lower  jaw  forward.  In  young  patients, 
for  its  correction,  the  movement  of  the  upper 
incisors  outward  to  close  in  front  of  the 
lower  ones  is  sometimes  sufficient,  but  when 
the  articulation  has  become  established  the 
cause  should  be  removed  when  possible,  and 
an  equalizing  device  or  a  chin-cap  applied 
to  force  the  jaw  backward.  (See  Chapter 
XVIII.,  Prognathism.) 
When  the  articulation  has  not  become  fully  established,  the  jaw 
can  sometimes  be  forced  backward  to  a  correct  occlusion  by  attach- 
ing an  inclined  plane  to  a  strong,  broad  collar  cemented  to  one  of 
the  lower  molars  on  each  side  of  the  arch,  projecting  back  of  the 
upper  molars  in  an  arrangement  reversed  from  that  shown  in  Fig.  405. 
Or  a  removable  apparatus  (Fig.  406)  can  be  applied  in  the  lower 
arch ;  it  should  be  strongly  anchored  to  the  molars  and  bicuspids, 
with  broad  spurs  projecting  upward  like  inclined  planes  to  rest  back 
of  the  last  upper  molars  in  occlusion,  and  when  necessary  similar 
spurs  pass  back  of  the  incisors  and  cuspids  or  other  teeth.  The 
inclines  should  be  rigid  or  made  of  heavy  gold  spring-clasp  metal, 
which  can  be  bent  forward  from  time  to  time.  When  it  is  required 
to  open  the  bite  to  permit  the  backward  movement  of  the  jaw, 
attach  bars  of  metal  to  the  si)ring-clasps,  arranging  them  to  pass  over 
the  grinding  surface  of  the  molars  and  bicuspids.  In  locating  the 
inclined  pianos  on  the   apparatus,  adjust  the  fixture  to  the  teeth, 


JUMPING  THE  BITE  BACKWARD 


343 


place  over  it  a  small  amount  of  modelling  compound,  and  direct  the 
patient  to  close  the  teeth  into  it,  making  a  bite.  The  device  is  then 
to  be  removed  with  the  compound,  transferred  to  the  articulator,  and 
filled  with  plaster.  After  taking  the  bite  in  this  manner  the  inclines 
can  be  fitted  to  the  teeth  of  the  opposite  arch  and  arranged  at  just 
the  angle  desired. 

When  the  molar  teeth  are  not  sufficiently  erupted  or  not  of  suit- 
able shape  for  the  application  of  the  devices  referred  to,  an  appli- 
ance with  a  base-wire  can  be  anchored  to  the  teeth  in  each  arch, 

Fig.  406. 


the  bite  taken  with  them  in  place,  and  spurs,  flanges,  or  inclines 
attached  to  the  upper  and  lower  appliances  so  as  to  engage  one  with 
the  other,  thus  forcing  the  lower  jaw  forward  or  backward  as  desired. 
In  the  latter  case  the  chin-cap  is  usually  employed.  When  extreme 
force  is  required,  an  equalizing  device,  as  shown  in  Fig.  388,  is 
effective. 

The  inclined  plane  was  used  to  advantage  in  jumping  the  bite 
backw^ard  for  Miss  I.,  aged  two  years  and  ten  months.  (See  Figs. 
184-186.) 


CHAPTER    XX 
LACK  OF  OCCLUSION 

The  regular  occlusion  of  the  teeth  is  not  infrequently  lacking,  both 
in  young  patients  and  in  the  adult.  The  malocclusion  may  be  general, 
there  being  no  reasonable  occlusion  of  the  upper  and  lower  teeth  in 
any  part  of  the  circle  of  the  arch  (Fig.  99) ;  there  may  be  an  im- 
proper articulation  on  one  side,  as  seen  in  Figs.  108  and  111. 
Other  forms  of  deficient  occlusion  are  termed  Lack  of  Anterior 
Occlusion,  Lack  of  Posterior  Occlusion,  Lack  of  Lateral  Occlusion. 

Lack  of  Anterior  Occlusion. — The  teeth  in  the  region  of  the 
incisors,  cuspids,  and  sometimes  the  bicuspids  have  more  or  less 
space  between  their  occlusal  surfaces,  the  teeth  in  the  back  part  of 
the  arch  standing  high  and  occluding.  Of  the  more  pronounced 
forms  of  lack  of  occlusion  this  is  perhaps  the  most  difficult  to 
correct.  The  irregularity  usually  occurs  in  the  upper  jaw,  although 
the  lower  may  be  changed  in  its  angle,  or  the  anterior  portion  of  its 
body  may  be  bent  downward,  sometimes  presenting  an  hyper- 
trophied  condition  of  the  alveolar  walls.  Imperfect  development 
of  the  bone  and  process  of  botii  the  upper  and  the  lower  arch  is 
usually  indicated  ;  it  may  be  the  result  of  nasal  disease  with  stenosis, 
and  is  usually  accompanied  by  mouth-breathing  and  enlarged  tonsils. 
The  buccinator  muscle  is  attached  to  the  outer  surface  of  the  alveolar 
process  of  the  jaws  opposite  the  molars,  sometimes  as  far  forward  as 
the  second  bicuspid  teeth.  The  continued  abnormal  separation  of 
the  jaws  causes  the  muscle  to  drag  on  the  processes,  and  this  tends 
to  elevate  the  molars  gradually,  inclining  them  with  the  bicuspids 
towards  the  inner  side  of  the  arch.  Lack  of  development  of  the  rami 
of  the  lower  jaw,  the  injudicious  extraction  of  teeth,  the  habit  of 
sucking  the  thumb,  and  mouth-breathing  are  also  factors  in  causing 
this  form  of  irregularity.     (See  Chaper  L,  Etiology.) 

Fig.  407  shows  the  features  of  Mr.  D.,  aged  seventeen  years,  a 
mouth-breather,  with  nasal  stenosis  and  enlarged  tonsils.  The 
lower  arch  was  broad  and  prominent,  as  is  generally  the  case  when 
the  tongue  is  continuously  drawn  downward  in  mouth-breathing, 
and  there  was  lack  of  development  of  the  ui)per  arch.     From  the 

844 


Fid.  407, 


Fig.  408. 


LACK   OF  ANTERIOR  OCCLUSION  345 

want  of  support  of  the  tongue  in  the  roof  of  the  mouth,  the  arch 
was  much  contracted ;  the  buccal  cusps  of  the  molars  occluded 
with  the  lingual  cusps  of  the  lower  molars.  There  was  a  con- 
siderable space  between  the  upper  and  lower  incisors,  with  inability 
to  close  the  lips.  This  interfered  with  enunciation.  The  upper 
arch  was  expanded,  and  for  forcing  the  jaws  together  a  chin-cap  was 
applied  supported  by  a  cranial-cap  and  rubber  umbrella  rings.  The 
latter  were  employed  to  give  the  considerable  force  required  for 
traction  (Fig.  408.  For  the  method  of  making  the  apparatus,  see 
Chapter  VII.,  Anchorage  and  Appliances,  pi).  97  and  100.)  The 
device  was  worn  at  night  and  as  many  hours  as  convenient  during 
the  day.  This  gradually  depressed  the  molars  and  improved  the 
occlusion,  permitting  the  lips  to  close  freely.  The  appliance  was 
continued  in  use  for  over  two  years. 

Fig.  409  illustrates  a  case  with  extreme  lack  of  anterior  occlusion. 
The  patient.  Miss  T.,  aged  seventeen  years,  was  referred  to  me  for 

Fig.  409. 


treatment.  She  was  suffering  with  nasal  stenosis,  and  breathed 
through  the  mouth.  The  lower  lip  was  thick,  and  was  drawn 
backward  over  the  lower  teeth,  the  end  of  the  tongue  resting  in  con- 
tact with  it.  The  upper  lip  was  also  thick,  but  appeared  considerably 
depressed,  causing  an  apparent  prognathous  condition.  It  was  only 
with  an  effort  that  the  lips  could  be  closed,  and  when  at  rest  they 
were  separated,  giving  the  face  an  unpleasant  expression. 

From  the  history  of  the  case  given  by  the  mother,  it  was  learned 
that  the  patient  had  been  a  mouth-breather  from  childhood,  and 
that  several  operations  had  been  performed  on  the  nose  by  rhinolo- 
gists  for  the  removal  of  the  stenosis,  but  they  had  afforded  only 
temporary  relief,  as  the  lips  could  not  be  kept  closed. 


346  LACK   OF  OCCLUSION 

All  of  the  teeth  but  the  third  molars  were  erupted,  none  of  them 
occluding  but  the  second  upper  and  lower  molars.  Between  the 
front  teeth  a  space  was  left  in  the  form  of  an  ellipse,  measuring 
about  five-sixteenths  of  an  inch  between  the  upper  and  lower  in- 
cisors at  the  median  line.  The  process  of  the  lower  jaw  was  much 
thickened,  the  mucous  membrane  spongy ;  all  of  the  front  teeth 
tipped  inward  and  were  shortened,  being  depressed  by  the  pressure 
of  the  lip  and  tongue.  The  vault  of  the  upper  arch  was  high  and 
contracted  laterally.  The  bicuspids,  cuspids,  and  incisors  needed  to 
be  moved  outward. 

It  was  found,  from  a  study  of  the  models,  that  the  teeth  of  the 
anterior  part  of  the  arch  could  be  made  to  approximate  fairly  well 
by  expanding  the  upper  arch,  destroying  the  pulps  of  some  of  the 
molars  on  each  side,  grinding  the  crowns  away,  also  dressing  a 
little  from  the  surface  of  the  bicuspids,  and  then  applying  a  chin-cap 
as  described.  The  patient  was  advised  to  adopt  this  plan  of  treat- 
ment, and  to  visit  the  rhinologist  again  for  the  improvement  of  the 

Fig.  410. 


condition  of  the  nasal  organs,  with  the  hope  of  making  her  a  nose- 
breather. 

To  expand  the  arch  and  move  the  incisors  outward,  an  appliance 
was  constructed  as  follows  (Fig.  410)  :  Spring-clasp  attachments 
were  made  to  pass  over  the  second  bicuspids,  with  i)artia]-clasps  on 
the  first  bicuspids.  The  anchorage  portions  were  connected  with  a 
palatine  spring  base-wire,  No.  14  B.  &  S.  gauge,  formed  to  cross 
the  arch,  with  a  U-shaped  loop  resting  at  the  median  line.  A  spring- 
wire,  No.  18  gauge,  was  bent  to  follow  the  lingual  contour  of  the 


LACK  OF  ANTERIOR  OCCLUSION  347 

incisors,  passing  under  lugs  on  collars  that  were  cemented  to  each 
of  the  laterals  ;  back  of  these  a  U-shaped  loop  was  formed  in  the 
wire  on  either  side,  with  the  end  of  tlie  loop  jjointing  towards  the 
median  line,  and  fitting  close  to  the  soft  tissues.  The  ends  of  the 
spring  were  then  curved  backward  and  united  with  solder  to  the 
anchorage. 

The  action  of  the  appliance  was  caused  by  opening  the  loops  in 
the  spring  for  moving  the  incisors  outward.  After  they  were  moved 
nearly  to  position,  the  loop  in  the  base-wire  was  broadened  for 
expanding  the  arch.  The  teeth  were  moved  outward  sufficiently, 
and  retained  with  the  same  appliance.  The  expansion  of  the  arch 
in  this  manner  elevated  the  incisors,  and  improved  the  occlusion 
and  general  appearance  of  the  teeth  and  of  the  features.  Prep- 
arations were  made  to  shorten  the  crowns  of  the  molars,  and  to  apply 
a  chin-cap,  but  the  patient  was  taken  ill,  and  for  retaining,  a  rubber 
plate  was  inserted,  covering  the  palatine  arch,  and  fitting  accurately 
the  necks  of  the  teeth.  After  three  years  the  conditions  were  found 
to  be  much  improved. 

The  chin-cap  was  used  after  the  expansion  of  the  upper  arch 
in  the  case  of  Mr.  L.,  a  minister  aged  twenty-four  years  (Fig.  411). 
The  patient  was  a  moutli-breather  with  progressive  lack  of  anterior 
occlusion,  the  lips  being  closed  with  difficulty,  interfering  with  speech. 
A  rhinological  operation  was  performed  and  the  chin-cap  applied, 
which  soon  caused  marked  improvement  in  the  breathing.  Fig.  412 
illustrates  the  apparatus  in  position.  It  was  worn  as  many  hours  as 
practicable,  gradually  elevating  the  jaw  and  permitting  the  lips  to 
close  easily.  In  a  years  time  the  occlusion  of  the  teeth  and  pronun- 
ciation were  quite  satisfactory,  but  the  patient  was  advised  to  continue 
the  application  of  the  chin-cap  with  lessened  force. 

I  have  treated  some  cases  of  lack  of  anterior  occlusion  which 
were  dismissed  with  a  feeling  of  dissatisfaction,  while  in  others 
the  treatment  proved  to  be  of  more  value  than  was  expected. 
In  the  case  of  Miss  S.,  none  of  the  teeth  in  front  of  the  second  bicus- 
pids occluded;  the  lower  jaw  closed  a  little  to  one  side.  These 
conditions  were  corrected  by  grinding  the  occluding  surfaces  of  the 
molars,  thus  permitting  the  teeth  in  the  front  of  the  mouth  to 
articulate.  To  improve  the  occlusion,  it  occasionally  becomes  neces- 
sary to  dress  a  good  deal  from  the  crowns  of  the  teeth,  in  some 
cases  to  destroy  the  pulps.     Dr.  Guilford  recommends  the  use  of  an 


348  LACK   OF  OCCLUSION 

anaesthetic  when  the  dentine  is  sensitive,  to  allay  the  pain  while 
grinding,  afterwards  making  repeated  applications  of  chloride  of 
zinc,  caustic  potasli,  or  nitrate  of  silver  for  obtunding.  When  this 
does  not  control  the  sensitiveness  of  tlie  dentine,  it  may  be  neces- 
sary to  devitalize  the  pulps  of  two  or  more  teeth  on  each  side  of 
the  arch,  and  subsequently  to  treat  and  fill  the  canals. 

When  there  is  a  considerable  lack  of  occlusion  that  would  require 
the  grinding  both  of  the  upper  and  lower  back  teeth,  I  tliink  it  is 
usually  better  to  preserve  the  lower  ones  and  to  extract  the  upper 
molars  and  sometimes  the  bicuspids  to  permit  the  approximation  of 
the  jaws,  and  to  insert  a  plate.  When  the  extraction  of  the  upper 
teeth  is  not  sufficient  to  let  the  jaws  come  together,  enough  of  the 
alveolar  process  and  gum  should  be  removed  to  favor  the  desired 
occlusion  and  also  to  allow  sufficient  space  for  the  introduction  of 
a  partial  upper  plate  of  metal  or  vulcanite.  If  the  space  procured 
by  the  removal  of  the  teeth  and  process  is  not  sufficient  to  admit 
the  use  of  porcelain  teeth,  a  bite  may  be  made  directly  on  a  metal 
plate,  or  white  vulcanite  used  to  represent  teeth  on  an  ordinary 
base-plate.  Usually  in  these  cases  the  distal  part  of  the  upper  arch 
is  much  vaulted,  and  the  treatment  in  this  manner  leads  one  out  of 
difficulty  without  the  grinding  and  final  destruction  of  the  lower 
molars,  at  the  same  time  causing  a  good  occlusion.  In  some  rare 
cases  the  same  method  of  treatment  can  be  applied  in  tlie  lower 
arch,  but  it  is  seldom  required. 

The  grinding  of  the  crowns  of  the  teeth  is  occasionally  necessary 
to  allow  the  teeth  of  one  arch  to  fit  more  closely  with  those  of  the 
opposite  arch.  This  is  sometimes  required  after  expanding  for  the 
correction  of  the  position  of  irregular  incisors;  a  procedure  which 
often  tips  the  molars  and  bicuspids  outward,  especially  when  the 
upper  arch  has  been  spread  to  much  extent.  The  new  position  of 
the  teeth  elevates  them,  opening  the  bite  and  separating  the  upper  and 
lower  front  teeth.  To  lessen  this  abnormal  condition  force  should 
be  applied  with  the  chin-cap  to  depress  the  teeth  on  the  sides  of  the 
arch,  or  the  cusps  of  the  teeth  that  prevent  the  proper  occlusion 
should  be  dressed  away.  The  latter  method  is  generally  preferred 
whfii  only  a  little  change  is  required.  When  done  judiciously  the 
grinding  is  not  a  material  injury  to  the  teeth,  and  the  final  result 
often  proves  satisfactory.     (See  Shaping  the  Teeth.) 

Lack  of  Posterior  Occlusion. — The  teeth  in  the  distal  jjart  of  the 


Fic.  411. 


Fui.  412. 


LACK   OF  POSTERIOR  AND  LATERAL  OCCLUSION 


349 


Fig.  413. 


arch  on  one  or  both  sides  of  the  circle  do  not  close  together,  while 
those  ill  the  front  of  the  arch  occlude. 

There  are  but  few  recorded  cases  of  continued  lack  of  occlusion 
of  the  posterior  teeth.  When  this  condition  exists  in  young  patients 
all  of  the  pressure  from  occlusion  is  exerted  on  the  front  teeth ;  this 
generally  drives  them  more  deeply  into  their  alveoli,  and  at  the  same 
time,  there  being  no  pressure  on  the  teeth  in  the  distal  part  of  the 
arch,  they  gradually  become  elevated  until  they  meet  with  those  of 
the  opposite  arch.  When 
only  the  incisors,  and  per- 
liaps  the  cuspids  occlude 
with  their  antagonists,  it  is 
generally  found  that  in 
chewing  the  patient  has  the 
liabit  of  moving  the  lower 
jaw  sufficiently  forward  to 
permit  the  lower  incisors  to 
close  in  front  of  the  upper  -  .  „. 

ones.     This  usually  allows  -  — ^»  -,»s.-i^B^ 

the    molars    and  bicuspids 

to  antagonize.     The  condition  may  be  improved  by  the  expansion  of 
one  of  the  arches,  or  by  wearing  a  chin-cap.     This  should  extend 

far  back  on  either  side  for 
causing  upward  traction 
under  the  body  of  the 
jaw,  the  cranial-cap  being 
placed  well  forward  on 
tlie  head  ;  when  necessary 
first  opening  tlie  bite. 

Dr.    Willis*    cites    the 
case  of  a  girl  aged  sixteen 
years  with    lack    of  pos- 
terior occlusion  (Fig.  413),  which  he  corrected  by  the  application  of 
gold  crowns  to  the  molars  and  bicuspids  (Fig.  414). 

Lack  of  Lateral  Occlusion. — The  teeth  in  the  region  of  the  bi- 
cuspids do  not  articulate,  while  there  is  a  good  occlusion  of  the  incisors 
in  the  anterior  and  the  molars  in  the  distal  part  of  the  arch.    This 


Fig.  414. 


*  Willis,  Dental  Cosmos,  1895,  p.  584. 


350  LACK  OF  OCCLUSION 

irregularity  is  generally  due  to  the  impaction  of  one  or  more  of  the 
teeth,  and  may  occur  on  one  or  both  sides  of  the  arch.  It  is  caused 
usually  by  the  tardy  eruption  of  the  bicuspids,  the  deciduous  teeth 
being  extracted  too  early  and  the  adjoining  teeth  crowded  into  the 
space.  It  may  also  result  from  heredity  or  arrested  development 
of  the  jaw  or  alveolar  process.  When  resulting  from  impaction  in 
young  patients,  the  broadening  of  the  space  will  usually  permit  the 
teeth  to  become  elevated  to  a  correct  level.  If  the  teeth  do  not 
take  a  good  position,  an  appliance  with  a  base-wire  supporting  a 
finger-spring,  shaped  to  engage  with  a  lug  on  a  collar  cemented  to 
each  of  the  teeth  to  be  moved,  should  be  applied  for  their  elevation. 
(See  Elevation  of  Bicuspids,  page  408.) 

When  it  is  determined  that  the  lack  of  occlusion  is  the  result  of 
heredity  or  arrest  of  development,  there  is  generally  no  advantage  in 
the  elevation  of  the  teeth  mechanically,  as  when  they  are  raised  in 
their  sockets  the  necessary  additional  bone  or  process  for  building 
up  is  not  usually  supplied,  and  when  the  retaining  device  is  removed 
the  teeth  settle  back  more  deeply  than  before  regulating.  Sometimes 
as  the  teeth  are  elevated  the  adjoining  ones  settle  more  deeply  into 
their  sockets. 


CHAPTER  XXI 

CUSPIDS,  TO  MOVE  OUTWARD— FORWARD  L\  THE  LINE  OF  THE  ARCH 

The  permanent  cuspids  are  erupted  from  about  the  tenth  to  the 
twelfth  year,  gradually  wedging  their  way  into  proper  line  in  the 
circle  of  the  arch.  When  from  the  premature  loss  of  the  deciduous 
cuspid  or  other  reason  the  space  between  the  adjoining  teeth  has 
become  too  narrow  for  the  admission  of  the  permanent  cuspid,  it  is 
frequently  caused  to  point  outward  and  take  a  more  or  less  promi- 
nent position,  or  it  may  incline  inward  and  take  a  position  inside  of  the 
line  of  the  arch.  The  former  accident  is  the  more  frequent ;  there 
are  more  cases  with  the  cuspids  too  prominent  than  inclining  inward. 

If  an  irregular  cuspid  is  not  forced  to  proper  line  soon  after  its 
eruption,  it  occasionally  becomes  necessary  to  extract  one  of  the 
bicuspids  to  admit  it  into  the  circle  and  prevent  overcrowding. 

During  its  eruption  the  cuspid  is  moved  readily,  but  its  root  is 
long,  and  after  the  alveolar  process  has  shrunken  around  it  and 
become  dense  it  often  requires  more  force  to  move  a  cuspid  than 
any  of  the  other  teeth.  In  the  adult,  all  of  the  teeth  used  for  anchor- 
age may  be  forced  more  or  less  out  of  position  before  it  will  yield, 
therefore  an  appliance  for  the  movement  of  a  cuspid  should  be 
firmly  anchored. 

A  thick  layer  of  alveolar  process  sometimes  prevents  tlie  tooth 
from  advancing  as  rapidly  as  it  should  when  force  is  applied.  In  this 
case  a  longitudinal  section  of  the  process  in  front  of  it  can  be  removed 
with  a  small  instrument,  as  a  trephine  or  pointed  barrel  bur,  to 
hasten  its  movement,  always  avoiding  injury  to  the  immediate  bony 
socket  about  the  root.  The  removal  of  alveolar  process  to  encourage 
the  regulation  of  teeth  in  other  parts  of  the  arch  is  sometimes  justi- 
fiable.* In  some  instances  the  retention  of  teeth  after  regulation  is 
assisted  by  removing  some  of  the  process  in  this  manner. 

Fig.  415  illustrates  a  device  that  was  used  for  moving  outward 
and  forward  a  right  upper  cuspid  for  Miss  A.,  aged  eighteen  years. 

The  lateral  incisors  had  not  erupted,  and  the  cuspid  closed  inside 

*  Jackson,  Dental  Cosmos,  1890,  p.  293. 

351 


352 


CUSPIDS 


Fig.  415. 


of  the  lower  arch.  A  palatine  base-wire,  No.  14  gauge,  the  founda- 
tion of  the  appliance,  crossed  the  arch  at  about  the  line  of  the  first 
bicuspids.     On  the  left  side,  it  was  anchored  by  partial-clasps  on 

the  cuspid,  bicuspids,  and  first 
molar,  with  a  spring-clasp  at- 
tachment around  the  second 
bicuspid ;  on  the  right  side  by 
a  spring-clasp  attachment  to 
the  first  bicuspid. 

The  spring  to  move  the 
cuspid  outward  was  attached 
to  the  partial-clasp  with  the 
end  of  the  base-wire  on  the 
left  side,  and  was  bent  into 
two  U-shaped  loops  about  three-eighths  of  an  inch  long,  forming  a 
letter  S.  The  other  end  of  the  spring  was  made  to  extend  in  a  gentle 
curve  across  the  arch  to  the  cuspid  to  be  moved,  where  it  was  bent 
nearly  to  a  right  angle  and  shaped  to  pass  underneath  a  lug  on  a 

Fig.  416. 


collar  cemented  to  the  tooth.  The  loops  in  the  spring-wire  were 
opened  to  give  the  desired  pressure.  It  is  always  well  to  arrange  the 
loop-shaped  portion  of  the  spring  on  the  opposite  side  of  the  arch 
from  the  tooth  to  be  moved. 

When  the  right  upper  cuspid  is  erupted  inside  of  the  line  of  the 
arch,  with  insufficient  space  to  admit  it  (Fig.  416),  an  appliance  can 


OUTWARD  OR   FORWARD   MOVEMENT  OF  CUSPIDS  353 

be  made  to  broaden  the  space  and  move  it  into  position,  by  adjusting 
a  rig^id  palatine  base-wire  to  cross  the  arch.  Anchor  its  ends 
strongly  by  partial-(las[)S  and  spring-clasp  attachments.  A  spring- 
wire  is  then  to  be  attached  to  the  base-wire  or  to  partial-clasps  on  the 
left  side,  where  it  is  formed  into  one  or  more  U-shaped  loops  with 
the  end  extending  across  tlie  arch  to  rest  on  the  cuspid  at  an  angle 
suitable  for  moving  it  outward. 

When  there  is  insufficient  room  to  admit  the  cuspid,  it  is  usually 
necessary  to  apply  force  for  increasing  the  space,  otherwise,  as  the 
cuspid  is  moved  outward,  one  or  more  of  the  adjoining  teeth  are 
likely  to  be  forced  with  it  and  assume  an  irregular  position. 

To  increase  the  space  between  the  lateral  incisor  and  first  bicuspid, 
a  U-shaped  spring  is  formed  by  bending  a  small  wire  twice  at  right 
angles,  the  distance  between  the  parallel  arms  being  equal  to  the 
antero-posterior  width  of  the  cuspid.  This  wire  is  sometimes 
soldered  to  the  end  of  the  looped  spring,  and  made  to  extend  over 
the  grinding  surface  either  side  of  the  cuspid  at  the  junction  with 
the  adjoining  teetli.  The  arms  are  then  bent  towards  the  gum  on 
the  labial  side  and  separated,  one  end  resting  on  the  labial  face  of 
the  lateral  incisor,  and  the  other  on  the  first  bicuspid. 

Springing  the  appliance  into  place,  after  separating  the  ends  of  the 
wire  last  described  by  bending,  tends  to  increase  the  space  for  the 
cuspid,  and  when  the  ends  are  curved  backward  they  cause  pressure 
on  the  labial  face  of  the  incisor,  and  the  bicuspid,  thus  assisting  in 
moving  the  cuspid  outward.  When  necessary  a  collar  with  a  small 
lug  on  the  lingual  side  may  be  cemented  to  the  cuspid  to  retain  the 
spring  in  position. 

If  the  tooth  has  not  become  too  firmly  set  in  the  socket,  the 
U-shaped  spring  last  described  may  be  used  alone  for  moving  a 
cuspid  outward. 

In  Fig.  417  is  shown  a  device  for  moving  outward  a  cuspid  wlien 
great  force  is  required.  The  anchorage  includes  all  of  the  teeth  but 
the  cuspid  to  be  moved.  It  is  made  with  a  broad  rigid  base- wire 
crossing  the  distal  part  of  the  arch,  and  a  lingual  base-wire  passing 
back  of  the  incisors.  These  are  anchored  with  partial-clasps  and 
spring-clasp  attachments  to  some  of  the  teeth  in  the  usual  manner, 
and  to  others  with  continuous  spring-clasps,  and  wire-clasps.  A 
large  spring  is  attached  to  the  anchorage  on  the  opposite  side  of  the 
arch  from  the  cuspid  to  be  moved.     It  extends  backward,  crossing 

23 


354 


CUSPIDS 


the  arch,  following  approximately  the  line  of  the  palatine  base-wire, 
then  extends  forward  like  an  arm  to  rest  under  a  lug  on  a  collar 
cemented  to  the  cuspid.     Force  is  caused  by  bending  the  end  of  the 


Fig.  417. 


Fig.  418. 


arm  outward.     Two  springs  of  this  character  can  be  utilized  when 

excessive  force  is  required. 

Fig.  418  shows  a  compensating  device  used  several  years  since  by 

the  author  to  move  outward  a  cuspid  that  had  a  lingual  occlusion, 

and  at  the  same  time  to  draw  into  line  a  prominent  lateral  incisor. 
It  was  made  of  spring-wire,  being  shaped  to  extend  around  the 

buccal  and  lingual  sides  of  the  molar,  and  bicuspids  at  the  gum  line. 
The  outer  and  inner  sides  of  the  device  were 
connected  by  passing  two  arms  of  wire  over 
the  arch  at  the  junction  of  the  teeth,  the  ends 
being  shaped  to  hook  over  the  wires  to  which 
they  were  soldered.  The  ends  of  the  spring 
were  left  free,  one  arm  extending  to  the  lingual 
side  of  the  instanding  cuspid,  and  the  other 
to  the  labial  side  of  the  prominent  lateral,  to 
move  these  teeth  to  their  respective  positions. 
With  this  form  of  device,  if  it  is  not  well 
retained,  partial-clasps  should  be  employed, 

and  a  collar  with  a  lug  on  the  lingual  side  cemented  to  the  cuspid, 

and  another  when  need  be  on  the  lateral  incisor. 

The  following  is  the  history  of  the  case  of  Miss  T.,  aged  sixteen 


OUTWARD  OR   FORWARD   MOVEMENT  OF  CUSPIDS 


355 


years.*  Both  of  the  lower  first  molars  had  been  extracted,  and  the 
second  molars  had  moved  forward  and  taken  their  place.  The 
upper  incisors  were  too  prominent,  and  the  laterals  were  twisted 
outward  so  that  their  edges  rested  across  the  lower  arch.  The  left 
upper  cuspid  was  about  one-third  erupted  and  was  inside  of  the  circle 
of  the  arch,  with  insufficient  space  for  it  in  proper  line.  The  removed 
teeth,  including  the  first  left  upper  molar,  had  been  extracted  by  a 
practitioner  who  inserted  a  vulcanite  plate  that  covered  the  roof  of 
the  mouth  and  extended  through  the  space  made  by  the  removal  of 
the  molar,  to  form  a  clasp  around  the  second  molar.  From  this 
projected  a  metal  point,  both  on  the  labial  and  lingual  side  of  the 
tooth,  for  the  attachment  of  four  rubber  bands  which  extended  to  and 
were  hooked  over  gold  spurs  that  projected  from  collars  cemented 
to  the  first  and  second  bicuspids  for  the  purpose  of  drawing  them  back- 

FiG.  419. 


ward  to  make  room  for  the  cuspid  and  lateral  incisor.  The  plate  was 
well  adjusted,  but  as  the  molar  was  very  short  it  ^yas  not  well  retained. 
The  patient  was  referred  to  the  writer,  and  an  appliance  made  as 
shown  in  Fig.  419.  A  base-wire  was  formed  to  follow  the  lingual 
side  of  the  teeth,  and  retained  with  wire-clasps  extending  nearly 
around  each  of  the  second  molars.  A  U-shaped  spring  with  long 
extending  arms  was  then  formed  so  as  to  pass  on  either  side  of  the 
second  left  molar  and  the  bicuspids,  and  attached  to  the  base-wire 
on  the  lingual  side.  One  end  of  the  spring  was  shaped  to  press 
outward  on  the  lingual  surface  of  the  instanding  cuspid,  and  the 
other  arranged  to  rest  on  the  mesial  surface  of  the  first  bicuspid  for 


*  Jackson,  Dental  Cosmos,  1891,  p.  1080. 


356 


CUSPIDS 


moving  it  and  the  second  bicuspid  backward  in  the  Hne  of  the  arch. 
The  U-shaped  spring  was  stiffened  by  connecting  the  sides  with  a 
wire  which  was  attached  to  the  base-wire  and  made  to  pass  outward 
just  in  front  of  the  molar. 

After  the  cuspid  was  nearly  in  correct  position,  a  new  appliance, 

as  shown  in  Fig.  420,  constructed  with  base- wire  and  partial-clasps, 

was  introduced  to  retain  the  teeth  that  had  been  moved,  and  to 

rotate  both  laterals  mesio-lingually.      As  the  teeth  were  prominent, 

-pj^^  ^^Q  the  second  bicuspid  on  the 

right  side  was  extracted  to 
relieve  the  crowded  condi- 
tion, and  the  first  bicuspid 
and  cuspid  were  moved 
backward  by  two  fmger- 
springs,  one  arranged  on  the 
buccal  and  the  other  on  the 
lingual  side,  as  described  for 
moving  the  bicuspids  on  the 
left  side.  At  the  same  time 
other  springs  were  added  to  the  appliance  for  rotating  the  lateral 
incisors.  The  object  was  to  have  a  spring-wire  with  a  straight  por- 
tion in  contact  with  the  lingual  side  of  the  tooth,  and  another  extend- 
ing from  the  base-wire  in  a  curve,  resting  on  the  labial  side  in  such 
a  manner  as  to  cause  pressure  for  rotating  it.  The  angle  of  the  ends 
of  the  springs  was  changed  pj^,  42], 

from  time  to  time  as  re- 
quired. Fig.  421  illustrates 
the  appliance  in  position. 

I  usually  depend  on  spring- 
pressure  for  moving  instand- 
ing  cuspids,  but  some  op- 
erators are  partial  to  the  use 
of  the  jack-screw.  It  can  be 
anchored  with  spring-clasp 
attachments,  as  shown  in 
Fig.  422,  or  a  palatine  base- 
wire  can  be  utilized  for  strengthening  this  form  of  anchorage,  having 
spring-clasp  attachments  extending  over  one  or  more  teeth  on  each 
side  of  the  arch.     In  making  the  appliance,  the  jack-screw  should  be 


OUTWARD  OR  FORWARD   MOVEMENT  OF  CUSPIDS 


357 


placed  in  position  on  the  model,  with  the  nut  in  contact  with  the 
partial-clasps  to  which  it  is  joined  with  soft  solder,  at  the  same  time 
uniting  the  anchorage  portion.  A  collar  is  then  cemented  to  the 
cuspid,  with  a  suitable  socket  to  hold  the  pointed  end  of  the  jack-screw. 

FiQ.  422. 


This  is  a  convenient  form  of  anchorage,  and  permits  of  easy 
removal  for  cleansing. 

When  one  or  both  of  the  upper  cuspids  are  inside  of  the  line,  with 
nearly  sufficient  space  for  them  to  take  a  normal  position  between 

Fig.  423. 


the  lateral  incisors  and  first  bicuspids,  constant  force  is  the  only 
requisite  for  moving  them  outward,  the  space  being  increased  by 
their  movement. 

A  convenient  form  of  device  for  their  correction  is  seen  in  Fig. 
423.     A  collar  with  a  lug  on  the  lingual  side  is  cemented  to  each  of 


358 


CUSPIDS 


the  cuspids  to  be  moved.  A  palatine  base-wire  is  anchored  with 
spring-clasp  attachments  to  the  first  molars  or  second  bicuspids, 
according  to  the  length  of  the  spring-arms  it  is  desired  to  use,  the 
arms  being  of  suitable  size  and  shaped  to  project  forward  from  the 
anchorage  on  either  side  to  rest  under  the  lugs  to  give  the  required 
force.  Generally  it  is  advisable  to  have  the  spring-arms  rather  long. 
The  base-wire  should  be  rigid,  being  made  of  a  large-sized  wire,  or 
of  two  or  more  smaller  wires  united,  and  located  well  back  if  other 
parts  of  the  arch  are  to  be  expanded  laterally,  when  a  slight  bend 
in  the  wire  is  sufficient  for  causing  lateral  force. 

Fig.  424  shows  a  method  employed  for  moving  outward  two 
instanding  upper  cuspids,  and  equally  available  for  moving  outward 
the  cuspids  of  the  lower  arch. 

A  spring  base- wire,  usually  No.  17  gauge,  is  formed  into  three 
U-shaped    loops,   each  about    three-eighths  of  an    inch    long;   the 

Fig.  424. 


middle  loop  pointing  backward  at  the  median  line,  and  the  other 
loops  resting  back  of  the  central  incisors,  the  outer  sides  being 
arranged  to  i)ress  against  the  lingual  surface  of  the  cuspids  to  be 
moved.  The  ends  of  the  spring  extend  backward  to  a  spring-clasp 
attachment  for  anchorage  on  either  side.  A  collar  with  a  lug 
soldered  to  it  in  suitable  position  should  be  cemented  to  each  of  the 
cuspids,  to  keep  the  spring  portion  of  the  appliance  from  slipping 
out  of  position.  Action  is  caused  by  opening  the  loops  in  the  spring 
for  the  desired  pressure. 

This  form  of  apparatus,  when  used   in   the   upper  arch,  can   be 
made  more  rigid  by  the  addition  of  a  palatine  base-wire. 


OUTWARD  OR   FORWARD   MOVEMENT  OF  CUSPIDS 


359 


A  simple  device  for  correcting  tiie  jDosition  of  npj)er  cuspids  tiiat 
have  erupted  inside  of  tlie  arch  and  recjuire  to  be  rotated  is  illus- 
trated in  Fig.  425.  A  collar  is  cemented  to  eacli  of  the  cuspids, 
with  a  tube  on  the  lingual  side  near  the  gum.     A  spring-wire  is 


Fig.  425. 


bent  into  a  broad  U-shaped  loop,  fitting  the  contour  of  the  roof  of 
the  mouth,  as  shown  by  the  dotted  lines,  or  the  spring  may  be 
extended  farther  back,  as  in  Fig.  457,  with  the  ends  bent  outward 
in  position  to  enter  the  tubes.  Force  is  brought  to  bear  on  the 
cuspids  for  their  movement,  by  bending  outward  the  arms  of  the 
loop,  while  at  the  same  time  the  ends  of  the  spring  that  enter  the 
tubes  are  bent  backward  in  form  to  give  the  force  for  rotating  them. 

If  more  force  is  required,  a  larger  spring  can  be  adopted,  or  an 
additional  spring  formed  into  a  large  loop  similar  to  the  one  de- 
scribed, its  ends  extending  into  other  tubes,  wliich  are  soldered 
longitudinally  to  the  collars  and  parallel  with  the  median  line  near 
the  gum,  as  shown  in  the  figure.  Or  a  short  section  of  tube  can  be 
attached  to  the  collar  in  a  perpendicular  position,  which  is  some- 
times preferred,  the  spring  being  bent  at  a  right  angle  to  enter  the 
tubes.  These  tubes  necessarily  have  to  be  dressed  away  before  the 
teeth  can  assume  a  normal  position. 

Springs  for  moving  the  teeth  in  this  manner  can  be  made  in 
various  forms. 

Fig.  426  illustrates  a  device  for  moving  outward  instanding  cus- 
pids, at  the  same  time  contracting  the  anterior  part  of  the  arch.  A 
palatine  base-wire  is  anchored  with  spring-clasj)  attachments  to  the 
second  bicuspids.     A  spring-wire  is  bent  into  three  U-shaped  loops, 


360  CUSPIDS 

conforming  to  the  palatine  arch,  the  centre  loop  pointing  backward 
at  the  median  line,  and  the  outer  sides  of  the  other  loops  resting 
under  lugs  attached  to  collars  cemented  to  the  cuspids.  The  ends 
of  the  spring  extend  backward,  and  are  attached  with  solder  to  the 

Fig.  426. 


partial-clasps  wdth  the  ends  of  the  base-wire.  The  opening  of  the 
loops  slightly  from  time  to  time  by  bending  forces  the  cuspids  out- 
ward, giving  room  for  the  inward  movement  of  the  incisors. 

A  semicircular  spring  for  contracting  the  anterior  part  of  the  arch 
is  fitted  to  the  labial  side  of  the  incisors,  with  a  loop  arranged  on 
either  side  opposite  the  cuspids.  The  ends  of  the  spring  extend 
backward  at  the  gum  line,  and  are  attached  to  the  spring-clasps  by 
passing  underneath  them  a  thin  narrow  piece  of  metal,  shaped  like  a 
partial-clasp  ;  they  are  united  with  solder,  or  they  can  be  arranged 
to  hook  into  eyelets  attached  to  the  spring-clasps.  Force  on  the 
incisors  is  applied  by  closing  the  loops  slightly. 

For  moving  cuspids  outward,  sometimes  a  labio-buccal  spring 
base-wire  can  be  used  by  attaching  spring-clasps  to  the  ends,  so 
located  and  shaped  as  to  hook  over  lugs  on  the  lingual  side  of  collars 
cemented  to  the  cuspids  or  the  ends  of  the  base-wire,  shaped  to 
hook  into  tubes  or  eyelets  attached  to  the  buccal  side  of  the  collars, 
the  base-wire  being  bent  outward  a  little  from  time  to  time  as  re- 
quired. In  the  same  manner  bicuspids  and  molars  may  be  moved 
outward  with  a  labii^-buccal  base-wire,  cither  by  liookiiig  into  tubes, 
by  individual  sprin^^-clasps,  or  by  coiitimious  spring-clasps  passing 
over  those  to  be  moved. 


OUTWARD  OR   FORWARD   MOVEMENT   OF  CUSPIDS 


361 


When  the  apparatus  employed  is  not  efficient  in  moving  cuspids 
outward,  or  forward  in  tlie  line  of  the  arch,  supplemental  force  may 
be  applied  as  seen  in  Fig.  144;  or  witti  an  infralabial  or  supra- 
labial  bar  similar  to  Fig.  373.     In  either  case,  a  collar  with  an  eyelet 


Fig.  427. 


on  the  labial  side  may  be  cemented  to  each  of  the  teeth  to  be  moved, 
as  shown  in  Fig.  427.  From  the  labial  spring,  or  bar,  a,  a,  curved 
wires,  6,  6,  are  arranged  to  extend  over  the  lip  to  hook  into  the 
eyelets. 


CHAPTER  XXII 

CUSPIDS,   TO   MOVE  INWARD— BACKWARD— ELEVATE— DEPRESS— 

ROTATE 

Moving  Cuspids  Idward — Backward  in  the  Line  of  the  Arch. — 
When  the  right  upper  cuspid  is  too  prominent  and  only  partially 
erupted,  with  insufficient  space  for  it  in  a  normal  position  (Fig.  428), 
the  following  method  of  moving  it  into  place  will  be  found  efficient: 
Form  an  anchorage  to  the  teeth  on  the  left  side  with  a  spring-clasp 
attachment  over  the  first  bicuspid  and  first  molar.  Attach  to  the 
anchorage  a  spring  bent  into  a  U-shaped  loop  resting  near  the  gum 
back  of  the  central  incisors,  with  the  end  extending  to  the  opposite 
side  of  the  arch  passing  back  of  the  lateral,  where  it  is  again  to  be 
formed  into  a  loop  as  wide  as  the  width  of  the  cuspid  to  be  moved ; 

Fig.  428. 


tiie  free  end  being  shaped  to  cross  the  mesio-lingual  surface  of  the 
first  bicuspid.  The  outer  part  of  the  loop  is  to  be  bent  upward  to 
rest  on  the  labial  side  of  the  cuspid  at  the  gum  line  for  the  purpose 
of  forcing  it  inward.  The  portion  of  the  spring  back  of  the  lateral 
incisor  is  gradually  straightened  to  broaden  the  space,  and  the 
desired  force  for  moving  the  cuspid  is  applied  by  curving  backward  the 
end  of  the  spring  on  the  lingual  .side  of  the  bicuspid,  at  the  same 
time  closing  slightly  the  U-shaped  loop  at  the  median  line. 

If  the  spring  is  not  well  retained,  a  partial-clasp  can  be  formed  to 
the  labial  side  of  the  cuspid  and  united  to  the  spring  with  solder; 

362 


INWARD  OR  BACKWARD  MOVEMENT  OF  CUSPIDS 


363 


or  a  collar  with  a  slight  lug  can  be  placed  on  the  lateral  incisor  or 
first  bicuspid.  When  the  cuspid  is  not  fully  erupted,  the  operator 
should  be  careful  not  to  wedge  it  between  the  adjoining  teeth  by 
applying  too  much  force  without  increasing  the  space,  as  the  lateral 
pressure  would  retard  its  eruption  ;  nor  should  he  let  the  shaj)e  of 
the  spring  in  any  way  interfere  with  its  downward  movement.  He 
should  first  broaden  the  space  and  then  force  the  cuspid  inward. 

In  cases  where  the  upper  cuspid  outside  of  the  line  of  the  arch  is 
fully  erupted,  with  the  space  between  the  adjoining  teeth  much  too 
narrow  for  its  admission,  and  it  has  been  determined  by  measure- 
ment that  it  is  not  necessary  to  extract  one  of  the  bicuspids  (Fig.  429), 
simple  pressure  on  the  labial  side  of  the  cuspid  will  not  usually  be 

Fig.  429. 


sufficient  for  its  correction,  as  the  force  will  often  move  the  adjoining 
teeth  towards  the  centre  of  the  arch.  The  latter  may  be  avoided  by 
an  appliance  made  in  the  following  manner : 

A  lingual  base-wire  is  formed  to  the  contour  of  the  arch  at  the 
gum  line,  the  ends  anchored  on  either  side  with  partial-clasps  and 
a  spring-clasp  attachment.  The  spring  for  moving  the  cuspid  is 
soldered  to  the  partial-clasps  with  the  base-wire,  made  to  pass 
through  the  space  in  front  of  the  first  bicuspid  near  the  grinding 
surface  at  the  junction  of  the  teeth,  and  bent  into  the  form  of  a 
loop  curving  upward  towards  the  gum  ;  it  crosses  the  labial  face 
of  the  cuspid.  The  front  arm  of  the  loop  is  shaped  to  pass  over 
the  arch  near  the  incisive  edge,  the  end  resting  on  the  disto-lingual 
surface  of  the  lateral  incisor.  The  space  is  increased  by  broad- 
ening the  loop  of  the  spring,  and  the  cuspid  is  forced  into  place  by 


364 


CUSPIDS 


curving  nearer  to  the  base-wire  the  portion  of  the  loop  that  crosses 
the  \abia\  side,  the  base-wire  preventing  the  adjoining  teeth  from 
being  pressed  inward. 

An  appHance  that  is  effectual  for  forcing  into  line  an  upper  cuspid 
that  has  erupted  too  prominently  and  anterior  to  its  normal  position 
is  shown  in  Fig.  430.     It  is  made  by  forming  a  lingual  base-wire  to 

Fig.  430. 


the  inner  curve  of  the  arch,  anchored  on  either  side  with  partial- 
clasps  and  a  spring-clasp  attachment. 

A  spring-wire  is  soldered  to  the  base-wire  opposite  the  incisors, 
it  having  been  bent  into  a  shallow^  loop  projecting  tow-ards  the 
median  line ;  the  spring  extends  over  the  arch  at  the  junction  of 
the  lateral  incisor  and  cuspid  near  the  edge,  where  a  secondary  loop 
is  formed  to  cross  the  mesio-labial  side  of  the  cuspid  near  the  gum, 
the  end  resting  on  the  mesial  surface  of  the  bicuspid.  The  location 
of  the  attachment  of  the  spring  to  the  base-wire  should  be  governed 
by  the  required  direction  of  pressure.  Force  for  moving  the  cuspid 
is  applied  by  bending  inward  the  whole  spring,  or  the  part  that  crosses 
the  labial  side.  When  the  space  is  insufficient  it  can  be  increased  by 
the  lateral  action  of  the  loop. 

The  two  following  figures  illustrate  the  case  of  Mr.  M.,  aged 
twenty-six  years.  The  patient  w^as  a  large-framed  man  with  dense 
bony  structures. 

In  the  upper  arch  the  right  cuspid  was  outside  of  the  circle  and 
very  prominent,  with  a  space  only  about  one-third  of  its  width. 
The  left  cuspid  and  the  lateral  incisors  were  also  irregular.  In  the 
lower  arch  the  first  right  bicuspid  and  cuspid  w^ere  too  prominent, 


INWARD  OR  BACKWARD  MOVEMENT  OF  CUSPIDS 


3(55 


with  little  more  than  sufficient  space  to  admit  one  of  them  in  proper 
position.     Tiie  incisors  were  much  crowded  and  irregular. 

After  a  careful  study  of  the  conditions,  it  was  not  deemed  ex- 
pedient to  expand  the  arches  sufficiently  to  admit  the  irregular  teeth. 
A  first  upper  and  lower  bicuspid  were  extracted,  and  appliances  made 
for  moving  the  cuspids  into  jjosition.  Both  a[)pliances  were  worn  at 
the  same  time. 

Fig.  431  shows  the  form  of  device  used  for  correcting  the  position 
of  the  upper  cuspid.     A  lingual  base-wire  was  shaped  to  follow  the 

Fig.  431. 


inner  curve  of  the  teeth ;  its  ends  were  anchored  on  each  side  by 
partial-clasps  and  a  spring-clasp  attachment.  The  sides  were  con- 
nected with  a  palatine  base-w^ire  to  give  more  stability  to  the  appli- 
ance. Partial-clasps  w^ere  also  arranged  on  the  lingual  side  of  the 
incisors  and  attached  to  the  base-wire  for  the  puri)ose  of  assisting 
the  anchorage.  A  stiff  spring  for  moving  the  cuspid  was  soldered 
to  the  partial-clasp  with  the  base-wdre  ;  it  extended  through  the 
space  just  in  front  of  the  second  bicuspid  to  the  buccal  side,  Avhere 
it  was  bent  forward  in  a  curve  to  rest  on  the  mesial  surface  of  the 
cuspid,  ending  in  the  shape  of  a  partial  hook.  The  spring  was 
curved  backward  from  time  to  time  to  cause  pressure  on  the  cuspid, 
and  as  it  moved,  the  end  of  the  spring  was  cut  away  to  prevent  it 
from  coming  in  contact  with  the  lateral  incisor. 

Fig.  432  illustrates  the  appliance  used  in  the  lower  arch.     Partial- 
clasps  w^ere  arranged  on  the  second  bicuspids  and  first  molars,  with 


366 


CUSPIDS 


wire-clasps  around  the  second  molars.  A  spring-clasp  attachment 
passed  over  the  first  molar  on  the  right  side,  but  owing  to  the  worn 
condition  of  the  teeth  no  spring-clasp  was  used  on  the  left  side. 
From  the  dense  structure  of   tlie  tissues  and  the  position  of  the 


Fig.  432. 


Kiiiiiiiiilii^illllll 


cuspid  it  was  evident  that  its  movement  would  require  more  than 
ordinary  force,  and  additional  anchorage  of  the  appliance  was  effected 
by  fitting  flat  pieces  of  metal  to  the  lingual  side  of  the  lateral  incisors 
in  front  of  the  base-wire  to  which  they  were  soldered.  These  metals 
were  bent  forward  later  for  moving  the  laterals  outward. 

A  strong  spring-wire  for  moving  the  cuspid  was  attached  to  the 
partial-clasp  by  the  base-wire  on  the  right  side,  and  extended 
forward  in  a  curve  to  pass  over  the  arch  at  the  junction  of  the 
cuspid  and  lateral  incisor,  where  it  was  bent  downward  to  the  gum 
line,  with  the  end  shaped  to  rest  on  the  mesio-labial  surface.  Addi- 
tional force  was  caused  as  required  by  bending  the  end  of  the  spring 
backward. 

Usually  this  form  of  spring  is  more  easily  controlled  when  at- 
tached to  the  base-wire  some  distance  back  of  the  tooth  that  is  to 
be  moved. 

When  an  upper  or  lower  cuspid  is  too  prominent,  with  insufficient 
sj)ace,  and  the  first  molar  has  been  removed  on  account  of  decay  or 
to  relieve  the  overcrowded  condition,  the  cuspid  can  be  moved  to 
proper  position,  and  the  bicuspids  at  the  same  time  moved  backward 
into  the  space  caused  by  the  extraction.  The  device  is  shown  in 
Fig.  433. 


INWARD  OR   BACKWARD  MOVEMENT  OF  CUSPIDS 


367 


A  stiff  lingual  base-wire  should  be  arranged  to  follow  the  inner 
curve  of  the  arch,  resting  in  contact  with  each  of  the  incisors,  with 
one  end  anchored  with  a  spring-clasp  attachment  to  the  second  left 
molar,  and  the  other  end  strongly  anchored  to  the  molars  and  bicus- 
pids.    When  necessary,  the  P      .„„ 
front  part  of  the  appliance  is                   -^  . ; 
further    retained    by    fitting 
partial-clasps  to  the  incisors 
and    attaching  them   to  the 
base-wire,  or  by  cementing 
to  one  or  more  of  the  incisors 
a  collar  with  a  slight  lug  to 
engage  with  the  base-wire, 
in  this  manner  utilizing  for 
anchorage    all   of  the   teeth 
that  are  not  to  be  moved. 
For  moving  the  cuspid  and 
bicuspids  backward  a  spring- 
wire,  No.  17  gauge  or  larger,  is  attached  to  the  base- wire  and  partial- 
clasp,  the  spring  being  shaped  to  extend  through  the  space  just  in  front 
of  the  second  molar  to  the  buccal  side,  where  it  is  bent  forward,  the 
end  terminating  on  the  mesio-labial  surface  of  the  prominent  cuspid. 

Generally  it  is  advisable  to  first 
start  the  bicuspids  in  their 
movement  by  a  U-shaped 
spring  attached  to  the  base-wire 
just  in  front  of  the  second 
molar.  The  arms  should  ex- 
tend forward  to  the  mesial  sur- 
face of  the  first  bicuspid,  one 
passing  on  the  lingual  and  the 
other  on  the  buccal  side.  Force 
is  caused  by  curving  the  ends 
of  the  springs  slightly  from  time 
to  time,  dressing  them  as  re- 
quired. 

Fig.  434  illustrates  a  similar 
device  that  has  given  satisfaction  for  moving  a  cuspid  and  two  bi- 
cuspids backward  when  considerable  force  is  required.     The  spring 


Fig.  434. 


a,  J, 


368  CUSPIDS 

is  attached  to  the  base-wire  opposite  the  bicuspids  to  be  moved.  It 
is  shaped  to  extend  forward,  passing  over  the  arch  in  front  of  the 
cuspid,  where  it  is  formed  into  a  double  U-shaped  loop  conforming 
to  the  surface  of  the  tooth,  with  the  end  curved  forward  to  rest  on 
the  mesial  and  labial  side  at  the  gum  line,  as  shown  at  o,  h.  To 
assist  in  moving  the  bicuspids  backward  an  additional  spring  is  some- 
times used  to  advantage  by  first  separating  the  teeth  with  a  wedge 
and  attaching  the  spring  to  the  base-wire.  It  is  first  bent  twice  at 
right  angles  with  the  distance  between  the  parallel  sides  a  little  more 
than  the  antero-posterior  measurement  of  the  first  bicuspid.  The 
ends  are  then  curved  downward  and  backward  towards  the  base-wire, 
and  left  sufficiently  long  to  rest  between  tlie  teeth  near  the  gum,  with 
one  end  arranged  to  cause  force  on  the  mesial  surface  of  the  secHDnd 
bicuspid  and  the  other  on  the  mesial  surface  of  the  first  bicuspid,  as 
shown  at  c,  d.  Force  is  applied  by  bending  backward  the  ends  of  the 
curved  springs,  first  moving  backward  the  second  bicuspid. 

Fig.  435. 


Fig.  435  illustrates  the  case  of  a  boy  aged  nine  years.  The  right 
upper  lateral  incisor  had  a  lingual  occlusion.  The  permanent  cuspid 
had  erupted  directly  in  front  of  it,  while  the  deciduous  cuspid  was 
still  in  place.  The  deciduous  incisors  were  lost  earlier  than  usual, 
two  of  them  being  joined.  Each  of  the  parents  had  full  rc'gular 
arches  of  teeth.  A  rather  unusual  ft-ature  in  the  case  was  the  erup- 
tion of  the  right  permanent  cuspid  before  the  loss  of  the  deciduous 
cuspids  or  molars. 

The  deciduous  cuspid  was  extracted  and  an  appliance  made  to 
correct  the  position  of  the  irregular  teeth.     A  lingual  base-wire  was 


INWARD   OR   BACKWARD  MOVEMENT  OF  CUSPIDS 


369 


applied  considerably  back  of  the  lateral  to  be  moved,  and  its  ends 
were  anchored  ])y  si)ring-clasp  attachments  to  the  deciduous  molars. 
The  permanent  cuspid  was  moved  into  place  by  a  curved  fmger- 
spring  soldered  to  the  partial-clasp  with  the  base-wire,  and  shaped  to 
pass  close  to  the  mesial  surface  of  the  first  deciduous  molar,  through 
the  space  caused  by  the  extraction  of  the  deciduous  cuspid.  It  was 
bent  forward,  ending  in  a  curve  on  the  mesio-labial  surface  of  the 
permanent  cuspid.  The  lateral  incisor  was  moved  outward  by  a 
finger-spring  fastened  to  the  base-wire  near  the  anchorage  on  the 
left  side  ;  it  followed  the  lingual  curve  of  the  arch,  extending  to  the 
distal  side  of  the  lateral  incisor,  and  passed  under  a  lug  on  a  collar 
for  anchorage.  Force  for  moving  both  of  the  teeth  at  the  same  time 
was  applied  by  the  springs. 

Fig.  43G. 


Fig.  436  illustrates  a  device  for  moving  into  line  a  right  upper 
cuspid  and  central  incisor  that  were  too  prominent,  with  insufficient 
space  for  them  in  the  arch,  and  at  the  same  time  moving  outward  an 
instanding  lateral. 

A  first  bicuspid  was  extracted  to  afford  the  necessary  space.  A 
lingual  base-wire  was  anchored  to  the  remaining  bicuspids  and  first 
molars.  The  cuspid  was  moved  backward  by  a  curved  finger-spring. 
A  similar  spring  was  attached  to  the  base-wire  just  back  of  the 
central  and  lateral  incisor  on  the  left  side,  in  connection  with  two 
inclined  planes  made  of  plate-metal.  It  was  shaped  to  extend  over 
the  arch  at  the  junction  of  the  central  incisors,  and  bent  at  a  right 
angle  to  rest  on  the  labial  face  of  the  prominent  incisor  near  the  gum. 

A    third  spring  was    attached    in    the    anchorage    on    the    right 

24 


370 


CUSPIDS 


Fig.  437. 


side,  and  cun^ed  forward  to  rest  on  the  mesio-lingual  surface  of 
the  lateral  incisor.  Force  was  applied  by  all  of  the  springs  at  one 
time,  gradually  moving  the  teeth  into  a  normal  circle.  A  spring 
shaped  like  the  one  extending  over  the  arch  at  the  median  line, 

can  be  used  to  move  several 
teeth  laterally  towards  one 
side. 

In  Fig.  437  is  shown  the 
position  of  the  teeth  of  Miss 
A.,  aged  fifteen  years. 

The  upper  cuspids  were 
very  prominent,  and  rested 
somewhat  over  the  lateral 
incisors,  forcing  the  laterals 
•  -^sffivs^-"^-  Qi^|.  Qf  place.    The  first  bi- 

cuspids had  moved  forward,  occupying  a  position  near  the  lateral 
incisors.  The  laterals  needed  to  be  moved  somewhat  outward. 
The  left  central  incisor  was  too  prominent,  and  required  to  be  moved 
inward.  The  first  upper  bicuspids  were  extracted,  and  an  appliance 
was  made  for  the  correction  of  the  position  of  the  irregular  teeth, 
as  shown  in  Fig.  438.  The  lower  incisors  impinged  upon  the  gum 
of  the  upper  arch,  necessi-  ^      .„„ 

tating  the  arrangement  of  the 
foundation  or  base-wire  of 
the  appliance  Avith  a  space 
between  it  and  the  upper 
incisors.  The  base-wire  was 
anchored  by  spring-clasp  at- 
tachments to  the  first  molars, 
partial-clasps  on  the  second 
bicuspids,  and  by  jjieces  of 
plate-metal,  No.  24  gaug(,', 
shaped  in  the  form  of  in- 
clined planes  resting  against 

the  lingual  side  of  the  lateral  incisors  ;  these  followed  the  contour  of 
the  gum  back  to  the  base-wire  to  which  they  were  soldered.  After 
the  cuspids  were  moved  to  position,  the  metal  inclined  planes  were 
bent  forward  slightly,  causing  pressure  on  the  lingual  side  of  the 
lateral  incisors  for  moving  them  outward,  while  at  the  same  time 


INWARD   OR  BACKWARD  MOVEMENT  OF  CUSPIDS 


371 


they  were  moved  laterally  by  curving  forward  the  inner  edge  of  the 
metals.  The  appliance  was  inserted  February  15,  and  the  teeth 
were  in  a  good  position  on  July  6,  the  appliance  being  worn  as  a 
retainer. 

In  moving  prominent  cuspids  inward  or  backward,  it  is  sometimes 
necessary  to  apply  supplemental  force  with  the  cross-bar  in  con- 
nection with  an  appliance  in  the  mouth,  as  otherwise  the  anchorage 
teeth  are  liable  to  be  drawn  forward  by  the  extreme  pressure 
required. 

Fig.  439  illustrates  a  cross-bar  device  that  was  used  in  1897  for 
the  backward  movement  of  the  lower  cuspids  in  the  case  of  a  young 


Fig.  439. 


man  aged  t\venty-two  years.  A  broad  collar  with  a  curved  piece  of 
flat  metal  as  long  as  the  width  of  the  tooth,  soldered  horizontally  to 
the  labial  side,  forming  a  groove  as  seen  at  a^  a^  Avas  cemented  to 
each  of  the  cuspids.  A  semicircular  wire.  No.  8  gauge,  with  the  ends 
bent  downward  and  at  an  acute  angle  towards  one  another,  as  shown 
at  6,  6,  with  the  right  distance  between  them  to  rest  in  the  grooves 
on  the  collars,  was  hinged  in  the  centre  to  the  cross-bar.  Force  was 
applied  by  elastics  and  straps  extending  from  a  cranial-cap  to  the 
knobs  of  the  cross-bar.  The  semicircular  wire  should  always  be 
shaped  to  interfere  as  little  as  possible  \vith  the  closure  of  the  lips. 

The  cross-bar  device  has  been  used  to  advantage  in  forcing  inw^ard 
or  backward  prominent  lower  and  upper  incisors,  cuspids,  bicuspids, 
and  molars  on  one  or  both  sides  of  the  arch. 

In  the  case  of  Miss  D.,  aged  twenty-four  years,  the  right  upper 


372 


CUSPIDS 


Fic.  440. 


cuspid  was  tardy  in  its  development,  and  the  bicuspids  and  molars 

had  moved  forward,  narrowing  the  space.     The  cuspid  was  elevated, 

and  supplemental  force  was  applied  with  the  cross-bar  to  reduce 

its  prominence  and  at  the 
same  time  to  move  back- 
ward the  bicuspids  and 
molars.  The  attachment 
of  the  cross-bar  to  these 
teeth  was  made  with  a  re- 
movable cap  and  socket 
retained  with  a  spring. 

Fig.  240  illustrates  an- 
other form  of  apparatus  for 
causing  supplemental  force 
in  moving  backward  any  or 
all  of  the  teeth  of  the  upper 

arch.     For  supplemental  force  in  moving  backward  the  teeth  of  the 

lower  arch,  see  Fig.  212. 

Fig.  440  illustrates  the  case  of  Miss  V.,  aged  eleven  years.*     The 

upper  cuspids  were  erupting  entirely  outside  of  the  line  of  the  arch, 

with   insufficient  space    to 

admit  them.   The  lateral  in- 
cisor on  the  left  side  rested 

nearly  in  contact  with  the 

first  bicuspid. 

A     spring     for     getting 

space,  moving  the  incisors 

outward    and    forcing    the 

prominent  cuspids  inward, 

was  shaped  as  seen  in  Fig. 

441.     The  spring,  No.  20 

gauge,    crossed    the    arch, 

following  the  lingual  curve, 

the  ends  passing  to  the  buccal  side  just  in  front  of  the  bicuspids. 

There  it  was  curved  forward  and  bent  back  on  itself,  forming  loops 

of  sufficient  size  and  depth  to  surround  the  cuspids  and  pass  again 

to  the  lingual  side,  terminating  on  the  disto-lingual  side  of  the  laterals. 


Fig.  441. 


*  Jackson,  Dental  Cosmos,  1889,  p.  855. 


INWARD  OR  BACKWARD  MOVEMENT  OF  CUSPIDS 


?,73 


Fig.  442.  To  the  spring  was  soldered  a  small-sized  base-wire, 
formed  to  extend  backward  on  either  side,  and  anchored  with  a 
spring-clasp  attachment  to  a  bicuspid  or  molar.  The  front  part  of 
the  appliance  is  best  retained  by  cementing  a  collar  with  a  groove 


Vic.  442. 


on  its  surface  to  one  or  more  of  the  teeth  on  each  side  of  the 
arch.  The  lateral  incisors  are  generally  chosen.  Retaining  collars 
are  not  required  in  all  cases.  After  the  collars  are  fitted  to  the 
teeth,  the  appliance  is  placed  in  position,  and  the  collars  are  marked 
below  its  line  of  contact.  They  are  then  removed,  and  a  small- 
sized  wire  is  soldered  to  the  marked  portion  to  form  a  groove,  after 
which  the  collars  are  cemented  to  place.  Collars  may  be  placed 
on  the  bicuspids  or  other  teeth  as  needed.  If  the  lateral  incisors 
are  to  be  moved  a  considerable  distance,  a  collar  with  a  spur  pro- 
jecting onto  the  lingual  side  of  the  central  incisor  should  be  cemented 
to  each.  When  all  of  the  incisors  are  to  be  moved  outward,  a  thin 
bar  can  be  shaped  to  the  lingual  side,  and  attached  with  solder  to 
collars  on  the  laterals,  thus  holding  all  of  the  incisors  in  the  same 
relationship. 

Similar  appliances  to  those  described  may  be  used  for  making 
room  and  forcing  prominent  lower  cuspids  into  line. 

If  the  arch  is  not  to  be  expanded  laterally,  or  the  position  of  the 
bicuspids  changed,  the  first  wire  crossing  the  arch  can  be  used  alone 
in  some  cases  by  employing  collars  on  the  lateral  incisors  and  first 
bicuspids ;  or  two  springs  may  be  arranged  to  cross  the  arch,  fast- 
ened in  the  centre  with  one  end  curved  to  encircle  the  cuspid,  and 
the  wires  separated,  acting  as  a  spring  to  gain  the  space  required. 


374 


CUSPIDS 


In  this  case  each  of  the  loops  that  passed  over  the  arch,  when 
spread  by  bending,  formed  a  spring  which  separated  the  lateral 
from  the  bicuspid,  making  room  for  the  cuspid.  The  end  of  the 
loop  was  then  bent  upward,  which  made  an  additional  spring  that 
pressed  on  the  labial  side  of  the  cuspid,  and  forced  it  into  line  as 
space  was  made  for  it.  "When  it  is  found  that  any  portion  of  the 
arch  back  of  the  cuspids  requires  to  be  expanded  to  assist  in  correct- 
ing the  irregularity  or  to  improve  the  occlusion,  the  arms  of  the 
base-wire  can  be  bent  outward. 

In  favorable  cases  it  may  not  be  necessary  to  anchor  the  ends  of 
the  base-wire  with  spring-clasp  attachments.  Curve  the  ends  of  the 
wire  onto  the  grinding  surface  at  the  junction  of  the  teeth  at  any 
place  in  the  distal  part  of  the  arch  that  will  not  interfere  with  the 
occlusion ;  this  will  prevent  the  apparatus  from  pressing  on  the 
gum. 

When  there  is  insufficient  space  and  it  is  found  necessary  to  extract 
a  bicuspid  to  give  room  for  a  prominent  cuspid  (see  Fig.  443),  cement 

Fig.  443. 


a  collar  with  a  tube  to  a  bicuspid  on  ilio  opposide  side  of  the  arch  to 
hold  one  end  of  a  base-wire,  which  follows  the  lingual  curve,  and 
anchor  the  other  end  by  a  spring-clasp  attachment  to  a  molar.  Or 
the  end  of  the  base-wire  may  terminate  in  a  curve  to  clasp  the  molar 
for  anchorage. 

If  the  first  bicuspid  and  cuspid  are  to  be  moved  l)ack\vard  into  the 
space  caused  by  the  removal  of  the  second  bicuspid,  make  a  loop  in  a 
spring-wire  to  cross  the  labial  surface  of  the  cusiiid  at  the  gum  line, 
with  the  ends  passing  through  the  space  to  the  lingual  side.     There 


INWARD  OR   BACKWARD   MOVEMENT  OF  CUSPIDS  375 

attach  one  end  to  the  base-wire  with  solder,  letting  the  other  rest 
free  on  the  mesial  side  of  the  bicuspid.  The  action  of  this  moves 
the  bicuspid  backward ;  and  at  the  same  time  the  looped  portion  of 
the  spring  is  to  be  curved  to  cause  pressure  on  the  cuspid  to  move 
it  into  line.  When  necessary  the  looped  portion  of  the  spring  can 
be  retained  by  cementing  to  one  of  the  incisors  a  collar  with  a  slight 
lug. 

The  inharmonious  development  of  the  teeth  in  young  ])atients 
often  misleads  the  inexperienced  operator  and  prompts  him  to  re- 
move teeth  that  should  be  saved  to  complete  the  arch,  make  a  good 
occlusion,  and  harmonize  the  features. 

For  lessening  the  prominent  effect  of  the  upper  arch  a  molar  or 
bicuspid  is  the  most  frequently  removed,  and  a  year  or  more  later  it 
is  found  that  the  lower  jaw  has  lengthened  and  broadened  without 
the  correspondmg  development  of  the  upper  jaw.     The  upper  lip 

Fig.  444. 


has  consequently  a  sunken  appearance  that  is  difficult  to  remedy, 
and  cannot  be  remedied  except  by  extraction  and  contracting  the 
size  of  the  lower  arch,  or  by  the  movement  outward  of  the  incisors 
and  cuspids  in  the  upper  arch.  But  the  latter  method  Avill  not 
always  correct  the  sunken  appearance  at  the  canine  eminence  and 
below  the  alea  and  low^er  part  of  the  nose,  which  can  only  be  im- 
proved by  moving  the  roots  of  the  teeth  bodily  outward. 

Fig.  444  illustrates  the  case  of  Miss  P.,  aged  twelve  years.  The 
first  bicuspid  on  each  side  of  the  upper  arch  had  been  removed  by 
another  practitioner  to  lessen  the  prominence,  and  later  the  lower 
arch  had  developed  so  that  the  cuspids  had  erupted  outside  of  the 
circle,  which  increased  the  unpleasant  expression  of  the  features. 


376 


CUSPIDS 


It  was  determined  by  measurement  that  the  contraction  of  the 
lower  arcli  by  the  width  of  one  tootli  would  be  sufficient  to  allow 
both  cuspids  to  be  brought  into  the  circle.  The  first  right  bicuspid 
was  therefore  extracted,  and  an  appliance  made  by  arranging  a  strong 
lingual  base-wire  to  the  inner  curve  of  the  arch,  anchored  on  either 
side  with  partial-clasps  and  a  spring-clasp  attachment.  A  spring-wire 
was  soldered  to  the  base-wire  on  the  right  side  opposite  the  second 
bicuspid,  passing  through  the  space  given  by  the  removal  of  the  first 
bicuspid.  Then  extending  forward,  the  end  terminated  in  a  curve  on 
the  mesio-labial  side  of  the  cuspid,  the  action  of  which,  by  curving 
the  end  of  the  spring,  moved  the  cuspid  backward  in  the  line  of  the 
arch,  close  to  the  second  bicuspid. 

A  similar  spring  was  attached  to  the  base-wire  opposite  the  second 
bicuspid  on  the  left  side.  It  extended  forward  to  the  mesial  side  of 
the  first  bicuspid,  then  over  the  arch  in  a  curve  at  the  junction  of 
the  cuspid  with  the  bicuspid,  and  was  formed  into  a  partial  loop  to 
cross  the  cuspid  at  the  gum  line.  The  action  of  the  spring  moved 
the  cuspid  into  line,  and  at  the  same  time  moved  the  four  incisors 
laterally  towards  the  right,  permitting  all  of  the  teeth  to  close  back 
of  those  in  the  upper  arch. 

The  deviation  from  the  median  line,  caused  by  moving  the  incisors 
laterally  in  the  lower  arch,  is  not  so  noticeable  as  in  the  upper. 

If  the  teeth  are  much  exposed  to  view,  they  should  not  be  moved 
laterally  without  first  examining  the   features   to  see   whether  the 

movement  would  be  detri- 
mental to  the  expression. 

Regulating  springs  of  any 
form  described  in  this  chap- 
ter can  1)('  used  in  connection 
with  a  well-anchored  plate. 

Fig.  445  illustrates  an  ap- 
pliance for  broadening  the 
space  f(jr  a  ijrominent  cusjjid 
and  moving  it  into  line.  A 
plate  is  formed  covering  the 
jjalatine  portion  of  the  arch, 
anchored  with  a  suction  in  the  centre  or  a  wire-clasp  around  one  or 
more  of  the  teeth  on  either  side. 

The   spring   for  moving    the  prominent  cuspid  is  bent  into  the 


INWARD  OR  BACKWARD  MOVEMENT  OF  CUSPIDS 


377 


form  of  a  loop  to  cross  the  labial  side  of  it  at  the  gum  line.  The 
ends  are  shaped  to  pass  throuf^h  the  space  between  the  adjoining 
teeth,  one  end  terminating  at  the  edge  of  the  plate  and  the  other 
attached  near  the  centre  in  the  usual  manner.  If  the  tooth  is  to  be 
moved  a  considerable  distance,  the  part  of  the  spring  that  rests  over 
the  plate  is  formed  into  one  or  two  U-shaped  loops.  When  the 
cuspid  is  to  be  moved  but  a  short  distance,  the  arm  of  the  spring 
should  be  left  straight  and  fastened  in  the  rubber  near  the  edge  of 
the  plate. 

This  form  of  spring  can  be  used  to  move  into  line  one  or  more 
prominent  upper  incisors,  when  the  occlusion  will  permit,  it  being 
properly  anchored  in  the  plate,  following  its  contour,  with  the  loop 
shaped  to  extend  over  the  incisive  edge  at  the  junction  of  the  teeth  to 
rest  on  the  labial  side,  near  the  gum,  as  shown  in  Figs.  217  and  223. 

When  first  molars  are  extracted  to  make  space  for  moving  promi- 
nent cuspids  backward  in  the  line  of  the  arch,  a  plate  with  springs, 
as  shown  in  Fig.  446,  may  be  employed.     The  plate  is  anchored  Avith 

Fig.  44G. 


wire-clasps  passing  around  the  second  molars,  the  anterior  part  rest- 
ing in  contact  with  the  incisors  and  the  curve  of  the  arch.  Rather 
large  finger-springs  are  attached  in  the  plate  next  the  second  molars, 
and  shaped  so  as  to  extend  forward  on  the  buccal  side  to  rest  on  the 
mesio-labial  surface  of  the  cuspids.  Additional  pressure  is  got  by 
bending  the  ends  of  the  springs  towards  the  plate,  wedging  the 
cuspids  to  place  and  forcing  the  bicuspids  backward. 


378 


CUSPIDS 


Fig,  447  illustrates  the  case  of  a  lady  aged  twenty-five  years,  in 
which  a  modified  split  plate  was  employed  for  expanding  the  upper 
arch,  it  being  much  too  narrow  to  articulate  with  the  lower,  and  at 


Fig.  447. 


the  same  time  moving  into  line  a  very  prominent  cuspid,  there  being 
insufficient  space. 

Generally  the  first  bicuspid  is  extracted  in  such  a  case,  but  as  the 
bicuspids  were  of  good  quality  and  the  first  molar  decayed,  the 
latter  was  extracted,  and  the  bicuspids  were  moved  backward  in  the 
line  of  the  arch  to  give  the  necessary  space.  The  plate  was  made  to 
cover  the  palatine  arch  (Fig.  448),  anchored  on  the  left  side  with 

Fig.  448. 


wire-clasps  extending  around  a  molar  and  a  second  bicuspid.  On  the 
right  side  it  was  anchored  by  a  wire-clasp  passing  around  the  second 
molar,  and  by  a  long  finger-spring  provided  for  moving  the  cuspid 
anrl  bicus[nds  backward.  The  spring  was  shaped  to  extend  from 
the  plate  through  the  space  next  to  the  second  molar,  and  to  reach 


ELEVATION  OF  CUSPIDS 


379 


forward  to  rest  on  the  mesio-labial  surface  of  the  cuspid,  where  it 
terminated  in  the  form  of  a  slight  hook. 

The  action  of  the  spring  was  caused  by  curving  tlie  end  nearer 
to  the  plate  from  time  to  time,  which  moved  the  cuspid  and  bicus- 
pids backward  into  line.  At  the  same  time,  the  U-shaped  spring 
that  joined  the  lateral  halves  was  separated  to  expand  the  arch. 
When  this  was  sufficiently  expanded,  and  the  teeth  were  in  position, 
they  were  retained  by  cementing  to  the  cuspid  a  gold  collar  with  a 
spur  on  the  lingual  side,  reaching  on  to  the  adjoining  teeth  (Fig.  502), 
and  a  thin  rubber  plate  was  inserted  to  maintain  the  width  of  the  arch. 

Elevation  of  Cuspms. — Fig.  449  shows  an  appliance  for  drawing 
into  position  a  cuspid  that  is  tardy  in  its  development  from  over- 
crowding or  other  cause,  or  pointing  in  a  wrong  direction. 

When  there  is  not  room  to  admit  the  cuspid  without  crowding  the 

Fk;.  44<). 


incisors  out  of  position,  the  arch  should  be  expanded,  or  the  first 
bicuspid  extracted,  but  the  bicuspid  should  not  be  removed  without 
first  making  accurate  measurements,  taking  into  consideration  the 
prospective  development  of  the  arch,  the  occlusion,  etc.  In  the 
case  illustrated,  the  first  bicuspid  was  extracted,  the  appliance  was 
constructed  with  a  lingual  base-wire,  anchored  by  partial-clasps 
and  a  spring-clasp  attachment  to  one  or  more  teeth  on  each  side  of 
the  arch.  Pieces  of  plate-metal  w-ere  shaped  to  rest  on  the  lingual 
prominences  of  the  teeth,  and  soldered  to  the  base-wire,  to  prevent 
it  from  pressing  on  the  gum.  When  required,  the  metals  can  be 
extended  in  the  form  of  a  hook  over  the  edges  of  the  incisors  and 


380  CUSPIDS 

on  to  the  grinding  surface  of  the  bicuspids  or  molars.  Occasionally 
wire  is  used  for  the  latter  purpose. 

A  spring-wire  was  attached  to  the  partial-clasp  by  the  base-wire, 
shaped  to  pass  through  the  space  next  to  the  second  bicuspid,  and 
to  extend  forward  in  a  gentle  curve,  terminating  on  the  labial  sur- 
face of  the  cuspid  to  be  moved.  When  the  cuspid  is  sufficiently 
advanced  in  the  process  of  eruption,  a  collar  with  a  pin  or  hook  in 
suitable  position  to  hold  the  end  of  the  spring  may  be  cemented  to 
it.  Or  if  the  tooth  is  not  sufficiently  erupted,  the  spring  can  be 
anchored  by  a  small  metal  pin,  screwed  or  cemented  into  a  pit, 
drilled  as  near  the  neck  of  the  tooth  as  practicable,  or  by  attaching 
a  small  eyelet  or  hook  in  the  same  manner  to  the  point  of  the 
tooth,  which  is  preferable  if  the  labial  side  is  covered  with  integu- 
ment. 

When  there  is  sufficient  space  for  the  admission  of  the  cuspid 
without  the  removal  of  an  adjoining  tooth,  the  spring  may  be  attached 
to  the  base-wire,  passing  over  the  arch  at  the  junction  of  the  bicus- 
pids, and  formed  to  extend  forward  in  the  manner  described. 

If  the  point  or  the  labial  face  of  the  cuspid  is  not  sufficiently 
exposed  for  operation,  the  soft  tissue  may  bo  forced  back  by  pressing 
sterilized  cotton  or  cord  between  it  and  the  tooth  daily  for  some 
time,  or  the  tissue  dressed  away.  If  the  cuspid  is  not  exposed,  the 
soft  tissue  may  be  removed  with  a  curved  bistoury,  and,  when  neces- 
sar}',  remove  some  of  the  alveolar  process  with  an  engine  bur.  When 
no  ordinary  means  of  attachment  to  the  tooth  can  be  made,  often 
the  end  of  a  spring  can  be  shaped  to  hook  over  the  cuspid  for 
drawing  it  downward  or  outward  until  a  collar  Avith  a  pin  can  be 
applied.  Undue  force  is  objectionable,  as  too  rapid  movement  of 
the  tooth  endangers  the  life  of  the  pulp. 

In  changing  the  adjustment  of  the  spring,  it  should  ha  bent  to  rest 
a  little  below  the  metal  pin  inserted  in  the  tooth  and  then  sprung 
over  the  pin  into  position.  In  this  manner  the  distance  the  tooth 
will  be  moved  by  the  spring  can  always  be  determined. 

It  is  unusual  for  the  cuspid  to  point  backward  and  rest  oppo.site 
the  buccal  surface  of  the  bicuspids.  When  found  in  that  position, 
or  when  the  cuspid  Ls  erupting  inside  of  the  line  of  the  arch,  the 
base-wire  can  be  shaped  in  suitable  form  and  anchored  as  described, 
the  spring  being  attached  and  bent  into  the  rcfiuircd  shape. 

A  method  of  elevating  an  improperly  erupted  cuspid,  as  presented 


DEPRESSION  AND  ROTATION  OF  CUSPIDS  381 

by  Dr.  H.  H.  Jackson,  is  as  follows  (see  Fig.  450):  A  thin  collar 
with  a  long  metal  tube  soldered  to  tlie  buccal  side  is  cemented  to  a 
first  molar,  the  tube  projecting  forward  at  the  gum  line  to  the  junc- 
tion of  the  bicuspids,  where  a  T  is  attached  to  assist  in  supporting 

Fig.  450. 


the  end  of  the  tube.  The  T  is  made  by  soldering  a  short  narrow 
piece  of  plate-metal  to  the  curved  end  of  a  wire  shaped  to  hook 
over  the  grinding  surface  to  engage  with  the  buccal  cusps  of  the 
bicuspids.  A  collar  with  a  pin  on  the  labial  side  is  cemented  to 
the  cuspid,  and  the  necessary  force  for  its  elevation  is  got  by  passing 
a  small  spring-wire  into  the  tube  and  springing  it  over  the  pin  on 
the  collar,  changing  the  shape  as  desired  for  causing  additional 
force.  When  supplemental  force  is  required  for  tlie  elevation  of  a 
cuspid,  an  apparatus  as  illustrated  in  Fig.  357  can  be  employed. 
For  other  means  of  elevating  the  cuspids,  see  Chapter  XVI.,  Incisors, 
to  elevate. 

Depression  of  Cuspids. — The  depression  of  cuspids  is  not  often 
required,  but  when  necessary,  apparatus  used  for  the  depression  of 
the  incisors  is  applicable.    (See  Chapter  XV.,  Incisors,  to  depress.) 

Rotation  of  Cuspids. — Apparatus  used  for  the  rotation  of  incisors 
is  applicable  for  the  rotation  of  the  cuspids,  although  each  part  should 
be  made  stronger  as  more  force  is  required.  Owing  to  the  shape  of 
the  crown  of  the  cuspid,  care  should  be  exercised  in  the  adjust- 
ment of  the  collar,  making  it  fit  well  at  the  neck  and  strongly 
cementing  it  to  prevent  it  becoming  displaced  when  force  is  applied. 
In  cementing,  the  end  of  the  collar  sliould  be  kept  covered,  to  force 
the  cement  forward  with  it. 


CHAPTER  XXIII 
BICUSPIDS,  TO    MOVE    OUTWARD    OR    IN    A    BUCCAL    DIRECTION 

Malposition  of  the  bicuspids,  like  malposition  of  the  incisors 
^nd  cuspids,  is  more  easily  corrected  when  the  arch  is  not  over- 
crowded. Unfortunately,  the  latter  condition  usually  accompanies 
the  irregularity.  Its  correction  generally  necessitates  the  use  of  an 
appliance  that  will  enlarge  the  circle  of  the  arch  and  at  the  same 
time  give  sufficient  force  to  move  into  line  those  teeth  that  are  out 
of  position. 

The  overcrowded  condition  of  the  bicuspids  is  often  caused  by 
premature  extraction  of  the  deciduous  molars,  either  on  account  of 
the  crowns  breaking  down  from  excessive  decay,  or  their  injudicious 
removal  resorted  to  to  relieve  pain. 

The  permanent  molar  teeth  have  a  tendency  to  move  forward 
in  the  line  of  the  arch  when  not  obstructed.  If  one  of  the 
deciduous  molars  is  removed  before  the  crown  of  the  relative 
bicuspid  has  reached  the  margin  of  the  gum  in  its  development,  the 
space  is  encroached  upon  by  the  gradual  movement  of  the  molars, 
and  often  becomes  too  narrow  to  admit  the  bicuspid  in  a  correct 
line.  Under  such  conditions,  the  bicuspid  may  force  its  way  to 
proper  position,  but  occasionally  it  is  deflected  to  the  inner  or  outer 
side  of  the  arch ;  or  it  becomes  rotated  or  impacted,  and  if  not 
liberated  by  broadening  the  space,  it  may  remain  in  an  impacted 
condition. 

Another  common  cause  for  rotation  or  deflection  of  the  bicuspids, 
is  the  presence  of  broken-down  carious  roots  of  a  deciduous  molar 
that  lias  lost  its  crown  from  caries.  After  losing  vitality,  the  roots 
are  absorbed  slowly,  and  act  as  an  obstruction  to  the  bicuspid  in  its 
regular  eruption. 

The  anterior  posterior  width  of  the  crown  of  a  deciduous  molar 
is  broader,  and  occupies  more  space  than  is  required  for  a  bicuspid 
when  erupted,  and  therefore,  if  the  deciduous  molars  are  retained, 
and  the  bicuspids  are  erupted  in  their  natural  order,  they  will  have 
ample  room  to  take  a  correct  position,  and  will  be  likely  to  do  so 
if  not  interfered  with  by  some  hereditary  or  acquired  influence. 

382 


OUTWARD  MOVEMENT  OF  BICUSPIDS 


383 


When  the  rig-ht  upper  bicuspid  lias  erupted  inside  of  the  circle  of 
the  arch,  and  the  space  between  the  cuspid  and  the  second  bicuspid 
is  sufficient,  or  nearly  so,  to  admit  it  (Fig.  451),  an  efficient  device 
for  moving  it  outward  is  made 
by  anchoring  on  the  opposite 
side  of  the  arch  the  end  of  a 
lingual  spring  base-wire  with 
partial-clasjis  and  spring-clasp 
attachments  to  the  molars  and 
bicuspids.  The  other  end  of 
the  base-wire  is  retained  by  a 
spring-clasp  attachment  pass- 
ing over  tlie  tooth  to  be 
moved.  Force  is  applied  by 
removing  the  a|)paratus  and 
bending  outward  the  sides  of 

the  base-wire.    This  appliance  is  also  suitable  for  moving  outward  a 
second  bicuspid. 

When  both  second  bicuspids  of  the  upper  or  lower  arch  are 
erupted  inside  of  the  normal  line,  with  sufficient  space  for  one  of 
them,  as  the  one  on  the  left,  and  insufficient  space  for  the  one  on 
the  right  between  the  adjoining  teeth,  their  position  can  be  corrected 
by  an  appliance  similar  to  the  one  shown  in  Fig.  452.  It  is  made 
with  a  lingual  spring  base- wire,  having  one  end  anchored  by  a 
Fig.  452.  spring  -  clasp    attachment 

to  the  bicuspid  on  the  left 
side,  and  the  other  end  to 
the  right  bicuspid  by  a 
partialTclasp  and  a  spring- 
wire  about  No.  22  gauge. 
The  spring  is  formed  to 
cross  the  partial-clasp  on 
the  lingual  side  of  the  bi- 
cuspid near  the  gum  line, 
with  the  ends  extending 
either  side,  up  and  across 
the  grinding  surface  at  the  junction  of  the  adjoining  teeth,  similar  to 
the  wires  of  a  spring-clasp.  The  ends  are  bent  sharply  again  towards 
the  gum,  then  separated,  forming  a  curve  so  that  they  will  rest  on 


384  BICUSPIDS 

the  buccal  side  of  the  adjoining  teeth.  All  of  the  metals  are  joined 
by  soldering,  completing  the  appliance.  It  will  be  observed  that  by 
removing  the  appliance,  and  separating  the  sides  of  the  spring-wire 
last  described,  the  tendency  will  be  to  increase  the  space  between 
the  first  bicuspid  and  first  molar,  while  at  the  same  time  the  ends 
of  the  spring  are  bent  backward  to  cause  pressure  on  the  adjoining 
teeth,  which  assists  the  action  of  the  base-wire  in  moving  the  right 
bicuspid  outward  to  proper  position. 

In  this  case,  the  bicuspid  on  the  left  moved  more  rapidly  than  the 
one  on  the  right,  as  it  was  not  so  crowded  in  the  arch,  and  when 
it  had  taken  a  proper  position,  the  anchorage  was  made  to  include 
the  first  molar  and  first  bicuspid. 

Fig.  453  illustrates  a  simple  device  that  is  applicable  for  moving 
outward  a  crowded  bicuspid  when  only  a  moderate  force  is  required, 

Fig.  453. 


first  broadening  the  space  for  its  movement.  It  is  made  like  the 
spring  previously  described.  A  partial-clasp  is  fitted  to  the  bicuspid 
to  be  moved.  A  small  spring-wire  is  used  for  a  spring-clasp  for 
anchorage,  with  a  slightly  larger  spring  shaped  to  extend  from  the 
partial-clasp  over  the  arch  either  side  of  the  bicuspid,  just  above  the 
spring-clasp,  its  ends  bent  outward  to  rest  on  the  buccal  side  of  the 
adjoining  teeth  near  the  gum.  The  arms  of  the  spring  are  bent 
outward  to  broaden  the  space,  and  the  ends  are  curved  backward 
to  give  force  for  moving  the  bicuspid  into  position. 

The  wires  should  never  pass  between  the  teeth  from  the  lingual 
to  the  buccal  side,  but  always  be  arranged  to  pass  over  at  the  grinding 
surface  and  junction  of  the  teeth. 


OUTWARD  MOVEMENT  OF  BICUSPIDS  385 

Generally  the  device  is  well  retained,  and  is  effective  without  the 
use  of  the  spring-clasp  attachment.  The  principle  of  the  appliance 
is  useful  in  many  combinalions. 

In  Fig.  454  is  shown  the  form  of  an  appliance  that  was  utilized  in 
the  case  of  Master  B.,  aged  fourteen  years,  to  correct  the  position 

Fig.  454. 


of  a  second  left  upper  bicuspid  that  was  erupting  considerably  inside 
of  the  arch  with  insufficient  space,  and  at  the  same  time  forcing  into 
line  a  prominent  cuspid.  The  patient  lived  many  miles  away, 
and  could  make  visits  only  at  long  and  stated  intervals.  The  teeth 
were  large  and  firmly  set  in  the  process.  A  palatine  base-wire  was 
anchored  with  spring-clasp  attachments  to  the  first  left  molar  and 
second  right  bicuspid.  A  lingual  spring  base-wire  was  formed  to  the 
inner  curve  of  the  arch,  with  a  loop  opposite  the  bicuspid  to  be 
moved ;  the  ends  were  soldered  to  the  partial-clasps  with  the  pala- 
tine base-wire,  the  end  of  the  loop  pointing  towards  the  median  line 
of  the  arch.  At  the  same  time  a  fmger-spring  was  attached  to  the 
partial-clasp  and  shaped  to  project  forward  in  a  curve  resting  near 
the  gum  on  the  lingual  side  of  the  bicuspid.  Action  was  caused  by 
opening  the  loop  in  the  lingual  base-wire  for  broadening  the  space, 
and  bending  outward  the  finger-spring  to  move  the  bicuspid.  The 
position  of  the  prominent  cuspid  was  corrected  with  a  spring  attached 
to  the  partial-clasp  and  base-wire,  extending  in  front  of  the  first 
bicuspid  to  the  buccal  side,  and  bent  forward  to  cross  the  cuspid  at 
the  gum  line,  with  the  end  curved  to  extend  over  the  arch  and  rest 
on  the  disto-lingual  side  of  the  lateral  incisor.  Force  was  caused 
by  bending  the .  looped  portion  inward  or  nearer  to  the  base- wire, 

25 


386 


BICUSPIDS 


Fig.  455. 


and  shaping  the  end  to  press  on  the  lateral  incisor  for  increasing  the 
space. 

The  device  shown  in  Fig.  455  has  been  used  in  favorable  cases 
for  drawing  into  line  a  bicuspid  that  was  inside  of  the  arch,  espe- 
cially when  there  was  sufficient  space'.  A  spring-wire 
is  bent  in  the  form  of  a  continuous  spring-clasp,  sur- 
rounding the  irregular  tooth  and  an  adjoining  one  on 
eacli  side,  resting  on  the  buccal  and  lingual  faces  near 
the  gum,  with  each  end  of  the  wire  terminating  upon 
the  tooth  to  be  moved  in  the  form  of  a  separate 
spring. 

The  appliance  is  more  firmly  anchored  when  partial- 
clasps  are  used  (see  Fig.  464). 
Many  appliances  described  in  other  parts  of  this  work  are  applica- 
ble for  moving  outward  the  bicuspids  (see  Figs.  128-130). 

An  appliance  used  for  moving  outward  the  first  upper  bicuspids 
for  Miss  T.,  aged  fourteen  years,  is  shown  in  Fig.  456.  A  lingual 
spring  base- wire  was  formed  to  the  inner  curve  of  the  arch,  with  the 

Fig.  45f). 


ends  anchored  with  spring-clasp  attachments  to  tlie  teeth  to  be  moved. 
Th(.'  action  of  the  base-wire  was  caused  by  straightening  the  curve 
from  time  to  time.  These  teeth,  being  closely  wedged  between  the 
adjoining  ones,  and  their  outer  cusps  articulating  deeply  inside  of  the 
cusps  of  the  lower  teeth,  Avere  especially  hard  to  move.  However, 
the  regulating  was  completed  in  a  moderate  time. 

The  appliance,  with   the  base-wire  in   this  form,  is  applicable  for 
moving  outward  bicusijids  in  the  lower  arch.     H\  by  measurement^ 


OUTWAED  MOVEMENT  OF  BICUSPIDS 


387 


it  is  found  tliat  tlie  length  of  the  base-wire  when  straightened  will 
not  be  sufficient  to  correct  the  position  of  the  irregular  teeth,  a  loop 
may  be  made  in  the  centre  or  arranged  as  illustrated  in  Fig.  457. 
The  latter  shape  is  usually  preferable  owing  to  its  greater  elasticity 

Fig.  457. 


and  ease  of  adjustment.  A  palatine  spring  base-wire  is  arranged  to 
cross  the  arch  near  the  molars,  the  ends  extending  forward  like 
arms  and  anchored  with  spring-clasp  attachments  to  the  teeth  to  be 
moved. 

A  base-wire  in  this  form   does  not  interfere  with  the   tongue  in 
pronunciation ;  the  arms  are  longer,  giving  more  action,  and  conse- 

FiG.  458. 


quently  the  appliance  is  more  easily  managed  and  does  not  require 
to  be  adjusted  as  often  as  the  one  previously  described. 

Fig.  458  shows  another  appliance  that  is  convenient  for  moving 
outward  two  upper  bicuspids.     A  palatine  spring  base-wire,  with  a 


388  BICUSPIDS 

U-shaped  loop  at  the  median  line,  is  anchored  by  spring-clasp 
attachments  over  the  teeth  to  be  moved.  The  base-wire  does  not 
interfere  with  the  tongue  in  pronunciation  when  made  to  cross  the 
arch  as  far  back  as  the  line  of  the  bicuspids.  The  action  is  readily 
controlled  by  spreading  the  loop. 

If  one  of  the  bicuspids  is  moved  to  position  before  the  other,  a 
partial-clasp  should  be  fitted  to  one  or  more  of  the  adjoining  teeth 
and  soldered  to  the  appliance  to  assist  the  anchorage  on  that  side. 

The  appliance  represented  in  Fig.  459  was  used  in  the  case  of  a 
physician,  aged    twenty-eight  years,   for    moving  outward    the  left 

Fig.  459. 


upper  bicuspids  and  a  lateral  incisor  that  had  a  lingual  occlusion,  the 
cuspid  being  in  good  position.  The  appliance  was  made  with  a 
palatine  spring  base-wire.  No.  14  gauge,  with  a  loop  formed  in  the 
centre  about  three-eighths  of  an  inch  long,  opening  towards  the 
front.  The  ends  of  the  base- wire  were  bent  nearly  to  a  right  angle, 
and  crossed  partial-clasps,  to  which  it  was  soldered,  with  a  spring- 
clasp  attachment  over  one  of  the  bicuspids  on  each  side  for  anchor- 
age. At  the  same  time  a  fmger-spring  was  soldered  in  the  anchorage 
on  the  right  side  and  made  to  reach  to  the  distal  face  of  the  lateral, 
following  the  lingual  curve,  where  the  spring  passed  under  a  lug  on 
a  collar  to  hold  it  in  position. 

The  incisor  was  moved  by  bending  outward  the  end  of  the  finger- 
spring,  and  the  loop  in  the  spring  base-wire  was  opened  from  time 
to  time  to  move  the  bicuspids  in  a  buccal  direction.  After  the  teeth 
were  in  position  the  same  appliance  was  used  to  retain  them.     Gen- 


OUTWARD  MOVEMENT  OF  BICUSPIDS 


389 


erally  with  this  form  of  device  the  anchorage  should  include  more 
teeth  on  tlie  side  that  is  not  to  he  moved. 

Often  the  sides  of  the  arch  are  flattened,  with  tiic  outer  cusps  of 
the  first  or  second  upper  bicuspids  closing  inside  of  the  line  of  the 
cusps  of  the  lower  ones,  and  the  anterior  part  of  tlie  arch  promi- 
nent. In  cases  like  this  it  is  desirable  that  the  bicuspids  be  moved 
outward  and  the  front  part  of  the  arch  forced  inward  to  permit  the 
teeth  to  articulate  more  perfectly  with  the  lower  ones.  An  appliance 
utilized  for  this  purpose  will  be  seen  in  Fig.  460.     It  is  made  with  a 

Fig.  460. 


lingual  spring  base-wire,  anchored  with  spring-clasp  attachments  to 
the  bicuspids  to  be  moved.  A  small  wire  is  attached  to  the  partial- 
clasp,  one  on  each  side  of  the  arch,  and  made  to  extend  to  the  buccal 
side  accompanying  the  spring-clasp,  with  the  end  bent  into  the  form 
of  a  small  eyelet  or  hook  located  about  midway  between  the  grind- 
ing surface  and  the  gum.  A  straight  spring-wire  is  bent  backw'ard 
across  the  front  of  the  prominent  incisors  and  passed  through  the 
hooks.  The  tendency  of  the  spring  to  straighten  assists  the  base- 
wdre  in  moving  the  bicuspids  outward,  and  at  the  same  time  causes 
pressure  on  the  labial  side  of  the  incisors,  moving  them  into  the 
desired  curve.  The  teetli  were  retained  with  a  palatine  plate,  as 
shown  in  Fig.  494,  having  a  small-sized  wire  of  a  semicircular  shape 
passing  in  front  of  the  incisors  and  back  to  the  first  bicuspids,  where 
U-shaped  loops  were  formed  in  the  wire  (a,  a),  the  ends  passing  over 
the  arch  at  the  junction  of  the  teeth  and  extending  into  the  plate. 

In  some  cases  a  metal  retainer  (Fig.  486)  will  be  more  comfortable 
to  the  patient.     It  is  easily  made  and  efficacious. 


390  BICUSPIDS 

A  labio-buccal  base-wire  can  be  used  independently  for  moving 
one  or  more  bicuspids  and  molars  outward.  Anchor  it  by  spring- 
clasp  attachments,  or  by  continuous  spring-clasps,  separating  the 
ends  of  the  base-wire  for  getting  force. 

For  young  patients,  when  both  the  upper  and  lower  bicuspids 
require  to  be  moved  outward  and  the  teeth  occlude  well,  an  appli- 

FiG.  461. 


ance  used  in  the  lower  arch,  if  the  teeth  are  moved  slowly,  will 
sometimes  move  the  teeth  of  the  upper  arch. 

Fig.  461  shows  an  irregularity  in  the  case  of  a  girl  aged  twelve 
years  that  was  corrected  with  finger-pressure.  The  second  right 
upper  bicuspid  was  erupting  inside  of  the  line  of  the  arch,  the 
deciduous  molar  still  being  retained. 

The  molar  was  extracted  and  the  patient  instructed  to  press  out- 
ward on  the  side  of  the  bicuspid  several  times  a  day,  which  gradually 
moved  it  into  line. 


CHAPTER  XXIV 
BICUSPIDS,    TO    MOVE    LNWARD    OR    IN    A    LINGUAL   DIRECTION 

With  ordinan^  methods,  where  the  teeth  are  crowded,  it  is  more 
difficult  to  move  a  prominent  bicuspid  inward  than  to  move  an 
instanding  bicuspid  outward,  the  direction  of  the  required  force  for 
moving  a  bicuspid  inward  being  such  as  to  tend  to  lessen  rather  than 
to  increase  the  size  of  the  arch,  wedging  the  teeth,  and  in  some  in- 
stances at  the  same  time  forcing  the  adjoining  ones  towards  the 
median  line.  For  this  purpose  an  appliance  can  usually  be  devised 
to  act  from  the  inner  side  of  the  arch.  It  is  less  conspicuous  and 
more  comfortable  to  the  patient  than  one  arranged  on  the  outer 
side. 

Fig.  462  shows  an  appliance  for  moving  into  line  a  prominent 
bicuspid  that  is  not  overcrowded.     It  is  made  by  shaping  a  spring- 

FiG.  462. 


clasp  attachment  to  the  tooth,  to  which  is  soldered  the  end  of  a 
heavy  lingual  spring  base-wise,  arranged  near  the  gum,  with  the 
other  end  of  the  base-wire  strongly  anchored  to  several  teeth  on 
the  opposite  side  of  the  arch.  The  irregular  tooth  is  moved  inward 
by  bending  together  the  ends  of  the  base-wire  slightly  from  time  to 
time. 

A  small-sized  spring-wire   can   be  attached  with  the  end  of  the 
base-wire  to  the  partial-clasp  on  the  tooth  to  be  moved.    The  spring 

391 


392 


BICUSPIDS 


is  shaped  to  extend  backward  and  rest  on  the  hngual  side  of  an  ad- 
joining tooth,  being  bent  outward  when  required  to  assist  the  action 

of  tlie  base-wire. 

When  the  teetli  in  the  arch  are  crowded  (Fig.   463)  an  appliance 

for  increasing  the  space  and  moving  a  prominent  bicuspid  into  posi- 
tion may  be  made  with  a 
Ungual  base-wire  properly- 
anchored.  Solder  to  it,  op- 
posite the  tooth  to  be  moved, 
a  spring-wire,  about  No.  12 
gauge  or  a  little  larger,  bent 
twice  at  right  angles,  the 
width  between  the  parallel 
arms  being  equal  to  the 
diameter  antero-posteriorly 
of  the  tooth  out  of  position, 
and  the  ends  shaped  to  ex- 
tend over  the  arch  on  either 

side  of  it  to  rest  on  the  buccal  face  near  the  gum.    There  is  a  space 

between  the  base-wire  and  the  tooth  that  is  to  be  moved,  while  the 

base-wire  is  in  contact  with  the  lingual  faces  of  the  adjoining  teeth. 

The  arms  of  the  spring  that  extend  from  the  base-wire  should  be 

formed  to  cross  the  space  near  the  gum  line,  and  curved  to  pass  over 

the  grinding  surface  at  the 

junction  of  the  teeth.    It  will 

be  seen  that  by  separating 

the  arms  slightly  by  bending, 

and  curving  the  ends  nearer 

the  base-wire,  the  tendency 

would    be    to   increase   the 

space  for  the  bicuspid,  and 

at  the   same   time  to  apply 

force  on  the  buccal  face  for 

moving  it  into  proper  line. 

One    spring   extending  over 

the  arch  in  this  manner  is  sometimes  sufficient  for  wedging  the  tooth 

into  place. 

Fig.  404  shows  a  device  used  for  moving  into  position  a  bicuspid 

erupting  outside  of  the  normal  line. 


Fig.  4(34. 


INWARD  MOVEMENT  OF  BICUSPIDS  393 

It  is  made  by  arranging  partial-clasps  on  the  lingual  surface  of  the 
teeth  either  side  of  the  bicuspid.  A  rather  stiff  spring-wire  is  bent 
into  a  slight  loop,  crossing  the  partial-clasps,  to  which  it  is  finally 
soldered  and  shaped  to  pass  over  the  arch  to  surround  the  adjoining 
teeth  loosely  in  the  form  of  a  continuous  spring-clasp,  with  the  ends 
terminating  on  the  buccal  side  of  the  tooth  to  be  moved.  The  space 
is  gradually  increased  by  straightening  the  looped  portion  of  the  wire 
a  little  at  a  time,  and  bending  the  free  ends  of  the  spring  inward  to 
cause  pressure  for  moving  the  bicuspid.  When  the  device  is  not 
well  retained  a  spring-clasp  can  be  added. 

An  appliance  arranged  on  the  outside  of  the  arch  as  seen  in  Fig. 
465  can  be  utilized  in  some  cases  for  moving  into  line  a  prominent 
bicuspid  on  one  or  both  sides,  whether  fully  or  partially  erupted. 

Fig.  465. 


It  is  made  by  fitting  partial-clasps  to  the  buccal  surface  of  the  teeth 
to  be  moved,  extending  the  metal  well  towards  the  neck  and  distal 
sides.  A  labio-J)uccal  spring  base-wire  is  shaped  to  follow  the  out- 
line of  the  teeth,  not  fitting  them  too  closely,  and  extended  to  the 
partial-clasps,  to  which  it  is  soldered.  The  appliance  is  removed 
from  time  to  time,  and  the  clasping  ends  of  the  spring  bent  tow^ards 
each  other  to  give  the  force  required.  A  U-shaped  loop  in  the  base- 
wire  sometimes  proves  of  advantage.  The  appliance  has  been  used 
for  general  contraction  of  the  arch  by  arranging  partial-clasps  and 
spring-clasp  attachments  on  the  teeth  as  required. 

A  few^  practitioners  are  still  using  and  recommending  cord  liga- 
tures and  rubber  bands  for  moving  irregular  teeth.  A  convenient 
device  for  holding  them  in  position  to  get  the  required  force  for 


394 


BICUSPIDS 


moving  bicuspids  is  made  as  shown  in  Fig.  466.  When  a  second 
right  upper  bicuspid  is  too  prominent  (a),  a  spring-clasp  attachment 
can  be  formed  to  the  first  bicuspid,  Avith  the  partial-clasp  arranged 
on  the  lingual  side.     A  small  straight  bar  of  wire  is  soldered  to  it, 


Fig.  466, 


extending  backward  to  rest  on  the  lingual  side  of  the  first  molar. 
A  rubber  band  or  ligature  is  then  placed  around  the  bar  and  the 
bicuspid  to  be  moved. 

When  the  first  left  bicuspid  is  inside  of  the  arch  (6),  it  can  be  moved 
outward  by  a  similar  appliance,  forming  a  spring-clasp  attachm.ent 
to  the  second  left  bicuspid,  with  a  partial-clasp  arranged  on  the 
buccal  side.  A  bar  shaped  to  extend  to  the  labial  side  of  the  cuspid 
is  then  soldered  to  it,  and  a  rubber  band  or  ligature  passed  around 
the  bar  and  the  bicuspid  to  be  moved. 


CHAPTER   XXV 
BICUSPIDS,    TO   MOVE    BACKWARD    IN   THE    LINE    OF   THE    ARCH 

The  cases  that  most  often  require  the  bicuspids  to  be  moved 
backward  in  the  line  of  the  arch,  are  those  where  a  molar  or  one  of 
the  bicuspids  have  been  removed  to  relieve  a  crowded  condition. 

Occasionally  the  removal  of  a  first  or  second  bicuspid  on  one  or 
both  sides  of  the  arch  is  required  to  cause  space  for  a  prominent 
cuspid,  or  prominent  or  overcrowded  incisors. 

For  such  conditions,  when  expansion  of  the  arch  is  not  practi- 
cable, the  writer  usually  recommends  the  extraction  of  the  first 
bicuspid  rather  than  the  second,  as  the  second  bicuspid  assists  the 
first  molar  in  anchorage.  Its  preservation  is  especially  necessary 
where  the  regulation  is  attempted  before  the  eruption  of  the  second 
permanent  molars.  After  the  eruption  of  the  second  molars,  the 
anchorage  would  consist  of  the  second  bicuspids,  the  first  and  second 
molars,  thus  having  three  teeth  on  either  side  to  sustain  the 
apparatus  in  moving  inward  the  six  front  teeth.  Even  with  the 
assistance  of  the  second  bicuspids,  the  teeth  used  for  anchorage  are 
liable  to  be  moved  forward  when  force  is  brought  to  bear  for  moving 
all  of  the  front  teeth  at  one  time.  The  anchorage  can  be  further 
strengthened  by  the  adoption  of  a  vulcanite  plate  covering  the  roof 
of  the  mouth,  its  added  value  being  measured  by  the  depth  of  the 
arch. 

The  matter  of  choice  as  to  the  extraction  of  one  of  the  bicuspids 
depends  much  upon  their  position,  occlusion,  shape,  size,  and  struc- 
ture. It  very  often  occurs  that  the  second  bicuspid  is  smaller  than 
the  first,  or  that  its  structure  is  not  equally  good.  In  such  case,  it 
is  wise  to  retain  the  first  bicuspid,  even  though  the  regulating  cannot 
be  accomplished  as  readily. 

Where  teeth  are  to  be  extracted  for  the  accommodation  of  others, 
they  should  not  be  removed  until  just  before  inserting  the  appliance 
for  the  correction  of  the  irregularity.  This  is  especially  important 
with  the  adult,  as,  owing  to  the  added  density  of  the  alveolar  process, 
it  is  not  easily  absorbed.  But  if  the  regulating  of  the  adjoining  tooth  is 
begun  before  the  bone  has  formed  in  the  socket  of  the  tooth  extracted, 

395 


396  BICUSPIDS 

the  root  can  be  moved  to  its  new  position  more  readily,  and  is  less 
liable  to  return.  The  recent  extraction  of  bicuspids  is  advantageous 
in  moving  cuspids,  either  when  they  are  too  prominent,  or  when  all 
of  the  front  teeth  are  to  be  moved  backward  into  line.  When  the 
second  bicuspid  is  extracted  to  give  room  for  a  prominent  cuspid, 
the  first  bicuspid  can  be  moved  backward  by  persistent  wedging,  or 
by  the  force  that  is  employed  for  moving  the  cuspid. 

Fig.  467  illustrates  the  case  of  a  girl  aged  fourteen  years.     The 
upper  incisors  were  much  too  prominent,  and  closed  in  front  of  the 

Fig.  467. 


lower  lip,  the  lower  incisors  biting  against  the  gum  considerably  back 
of  them.  The  case  was  referred  to  the  writer  under  the  condi- 
tions illustrated.  The  second  bicuspids  had  been  removed  with  the 
expectation  that  the  incisors,  cuspids,  and  first  bicuspids  would 
move  backward  in  the  arch ;  but  instead,  the  molars,  following  the 
usual  tendency,  moved  forward,  encroaching  upon  the  space  caused 
by  the  removal  of  the  second  bicuspids.  As  anchorage  to  the  first 
and  second  molars  would  not  be  sufficient  to  move  the  first  bicus- 
pids, cuspids,  and  incisors  at  one  time,  the  regulation  was  divided 
into  two  operations,  first  moving  the  cuspids  and  bicuspids  back- 
ward. By  this  plan  the  anchorage  of  the  appliance  could  be 
improved  by  means  of  a  vulcanite  plate,  covering  the  roof  of  the 
mouth,  the  front  part  of  it  resting  against  the  anterior  palatine  arch 
and  the  lingual  side  of  the  incisors ;  and  the  distal  part  retained 
by  wire-clasps  around  the  second  molars.  The  plate  was  firmly 
anchored,  and  at  the  same  time  the   front  part,  being   somewhat 


BACKWARD  MOVEMENT  OF  BICUSPIDS  397 

thickened,  caused  the  lower  incisors  to  be  depressed  in  their  sockets 
through  occlusion.  For  moving  the  bicuspids  and  cuspids,  a  spring- 
wire  was  extended  from  the  plate  outward  on  each  side,  passing 
through  the  space  close  in  front  of  the  first  molar,  with  the  end  of  the 
spring  curved  forward  and  shaped  to  rest  on  the  mosio-labial  surface 
of  the  cuspid.  Tlie  springs  were  shaped  to  pass  through  the  space 
near  the  grinding  surface  of  the  teeth  rather  than  near  the  gum,  to 
allow  the  first  bicuspids  to  be  moved  backward  in  close  contact  with 
the  molars. 

The  edge  of  the  plate  opposite  the  cuspids  and  first  bicuspids  was 
made  straight  and  smooth  to  permit  their  backward  movement. 
Action  of  the  springs  was  caused  by  bending  them  in  proper  curve 
towards  the  plate  from  time  to  time,  the  ends  being  made  shorter 
when  required  by  dressing  with  a  corundum  stone.  When  these 
teeth  were  moved  backward  into  position,  similar  springs,  as  shown 
in  Fig.  242,  were  extended  from  the  plate  in  front  of  the  cuspids  to 
the  labial  side  of  the  incisors  for  moving  them  inward.  But  for  this 
purpose  it  is  usually  better  to  construct  an  entirely  new  appliance. 

The  cuspids  and  first  bicuspids  had  not  become  firm  in  their  new 
position,  and  it  was  not  considered  advisable  to  depend  on  the 
anchorage  of  the  plate  alone  for  moving  the  incisors.  Accordingly 
supplemental  force  was  applied  by  a  cross-bar  (Fig.  69)  worn  at  night, 
and  the  regulating  w^as  completed  in  a  limited  time. 

Fig.  468  shows  an  appliance  for  correcting  the  position  of  a  left 
lower  cuspid  that  was  much  too  prominent,  with  insufficient  space, 
and  closing  in  front  of  the  teeth  of  the  upper  arch.  The  occlusion 
would  not  permit  the  enlargement  of  the  arch,  and  therefore  the 
extraction  of  one  of  the  teeth  was  required  to  give  space  to  allow 
the  cuspid  to  take  a  correct  position.  Usually  when  extraction  is 
necessary,  if  the  first  permanent  molar  is  of  good  structure,  the 
first  or  second  bicuspid  should  be  removed,  preserving  the  one 
that  is  found  on  careful  examination  to  articulate  the  better  and 
more  strongly  when  it  and  the  cuspid  are  moved  backward  into 
position. 

In  this  case  the  molar  was  defective.  It  was  extracted,  and  the 
bicuspids  were  moved  backward.  An  appliance  was  made  by  form- 
ing a  rigid  lingual  base-wire  to  the  inner  curve  of  the  arch,  fitting 
well  to  the  incisor  teeth,  following  the  line  of  the  gum  to  the  second 
molars.     For  anchorage,  carefully  fitted  partial-clasps  were  arranged 


398  BICUSPIDS 

on  all  of  the  teeth  not  to  be  moved,  with  a  spring-clasp  attachment 
over  the  second  left  molar  and  a  wire-clasp  passing  back  of  it,  and 
a  spring-clasp  attachment  over  the  first  bicuspid  and  first  molar  on 
the  right  side,  with  a  wire-clasp  passing  around  the  second  molar. 
For  moving  the  bicuspids  backward,  they  were  first  wedged  a  little. 
A  double  spring  was  attached  to  the  base- wire  opposite  the  first  bicus- 
pid. The  spring  was  bent  twice  at  right  angles,  with  a  little  more 
space  between  the  parallel  arms  than  the  antero-posterior  measure- 
ment of  the  bicuspid.  The  ends  were  curved  downward  and  again 
towards  the  base-wire  as  shown  at  e,  d.  Force  was  caused  for 
moving  the  teeth  by  bending  backward  the  ends  of  the  arms  from 
time  to  time.  When  teeth  are  to  be  moved  some  distance  with  this 
form  of  spring,  it  can  be  moved  backward  on  the  base-wire  when 
required  and  resoldered.  For  this  purpose  an  adjustable  attach- 
ment has  been  devised  by  using  a  square  base-wire,  fitting  to  it  a 
tube  to  which  the  spring  is  attached  and  held  with  a  ratchet.  The 
cuspid  was  moved  with  a  spring  attached  to  the  base-wire,  passing 
over  the  arch  at  the  junction  with  the  lateral  incisor,  where  it  was 
bent  into  a  U-shaped  loop,  extending  across  the  face  of  the  cuspid, 
with  the  end  terminating  on  the  mesio-labial  surface  near  the  gum, 
as  shown  at  a,  h  ;  force  being  got  by  bending  backward  the  end  of 
the  spring. 

In  Fig.  469  are  shown  the  features  of  Miss  M.,  aged  fourteen 
years,  a  case  of  double  protrusion  regulated  in  1896. 

The  teeth  of  both  the  upper  and  lower  arch  were  overcrowded, 
the  incisors  being  much  too  prominent,  with  the  upper  incisors 
rotated  and  resting  on  the  lower  lip,  giving  the  mouth  a  full  and 
unpleasant  expression.  Each  arch  was  sufficiently  broad,  and  ex- 
pansion for  lessening  the  anterior  prominence  was  not  practical.  It 
was  therefore  necessary  to  extract  a  tooth  on  either  side  of  both  the 
upper  and  lower  arches.  It  was  found  from  general  measurement, 
and  from  the  anterior-posterior  width  of  the  bicuspids,  that  the  re- 
moval of  either  the  first  or  the  second  would  not  furnish  sufficient 
space  for  the  correction  of  the  irregularity.  Again,  the  structure  of 
the  bicuspids  was  good,  while  each  of  the  first  Jiiolars  had  several 
large  fillings  reaching  near  the  pulp,  therefore  the  interest  of  the 
patient  demanded  the  preservation  of  the  bicuspids  and  the  removal 
of  the  defective  teeth,  even  though  it  would  add  much  to  the  work 
of  regulation.     The  upper  sixth  year  molars  were  first  extracted 


Fig.  468. 


Fig.  469. 


BACKWARD  MOVEMENT  OF  BICUSPIDS  399 

and  wedges  immediately  inserted  back  of  tlie  cuspids,  giving  space 
to  admit  springs  for  the  distal  movement  of  the  bicuspids. 

An  appliance  was  made  with  a  palatine  vulcanite  plate,  anchored 
with  wire-clasps  extending  from  the  distal  part  of  it  around  each  of 

Fig.  470. 


the  second  molars.  The  front  part  of  the  plate  rested  in  contact  with 
the  lingual  side  of  the  incisors  and  cuspids,  with  short  pieces  of 
wire  projecting  from  the  plate  into  the  interdental  spaces  back  of 
the  cuspids.  Springs  with  the  ends  flattened  were  attached  in  the  rub- 
ber near  the  centre  of  the  plate,  on  a  line  with  the  junction  of  the 
bicuspids ;  the  free  ends  were  bent  forward  in  a  gentle  curve  to  pass 
through  the  space  caused  by  the  Aveclging  to  the  buccal  side,  where 
they  were  bent  forward  at  a  right  angle,  leaving  a  little  space  between 
the  end  and  the  cuspid  (Fig.  470,  «,  a).  Force  was  given  by  bending 
the  ends  of  the  springs  backward  from  time  to  time.    It  was  foreseen 

Fig.  471. 


that  the  anchorage  was  liable  to  prove  insufficient,  and  supplemental 
force  with  a  cross-bar  was  employed.  A  large  wire  was  shaped  in 
a  semicircle  to  conform  to  the  anterior  curve  of  the  arch  long 
enough  to  reach  from  the  ends  of  the  springs  a,  a,  and  to  leave  a 


400  BICUSPIDS 

considerable  space  in  front  of  the  incisors.  A  thin  piece  of  plate- 
metal  was  then  wound  around  either  end  of  the  wire,  broad  enough 
to  project  about  three-sixteenths  of  an  inch,  and  soldered,  forming 
cylinders  (Fig.  471,  6,  b)  to  pass  over  the  projecting  ends  of  the 
springs  a,  a.  The  centre  of  the  wire  was  hinged  to  a  double  cross- 
bar by  bending  around  and  soldering  to  each  a  suitably  shaped  piece 
of  plate-metal,  with  the  ends  of  one  projecting  between  the  ends  of 
the  other  and  held  by  a  pin.  The  apparatus  when  adjusted  ap- 
peared as  seen  in  Fig.  472.  It  was  worn  at  night,  and  when  con- 
venient during  the  day.  The  tension  of  the  elastic  bands  from  the 
cap  imparted  additional  force  to  the  springs  a,  a,  causing  the  rapid 
backward  movement  of  the  bicuspids  bodily,  closing  the  spaces  caused 
by  the  extraction  of  the  first  molars  without  any  apparent  change  in 
the  position  of  the  anchorage  teeth.    The  result  is  shown  in  Fig.  473. 

This  case  illustrates  the  advantage  in  not  extracting  teeth  that 
are  to  provide  space  until  the  time  of  the  commencement  of  the 
regulation.  There  being  a  comparatively  open  socket,  the  teeth  are 
moved  more  rapidly  and  are  more  likely  to  be  moved  bodily  in  the 
direction  desired. 

The  upper  incisors  and  cuspids  were  moved  backward  with  a 
similar  palatine  plate  anchored  with  wire-clasps.  Springs  were 
attached  in  the  vulcanite,  one  on  either  side,  shaped  to  extend 
through  the  space  in  front  of  the  first  bicuspids  and  curved  forward 
to  rest  on  the  mesial  surface  of  the  incisors,  terminating  a  little 
beyond  the  median  line,  one  above  the  other  (Fig.  242).  With  the 
springs  in  this  form  the  bicuspids  were  retained  in  position.  When 
they  were  sufficiently  firm  the  anterior  edge  of  the  plate  was  dressed 
away  at  regular  intervals,  and  the  springs  curved  to  give  slight  press- 
ure on  tlie  incisors  for  moving  them  and  the  cuspids  backward. 
The  force  was  effective  without  the  application  of  a  cross-bar,  and 
did  not  change  the  position  of  the  teeth  used  for  anchorage ;  but 
generally  with  these  conditions  a  cross-bar  should  be  employed.  At 
the  same  time  an  apparatus  was  applied  for  correcting  the  position 
of  the  lower  teeth,  first  forcing  bodily  backward  the  bicuspids.  The 
first  molars  were  extracted,  and  a  wedge  was  applied  back  of  each 
of  the  cuspids  to  get  space  for  the  springs  of  an  apparatus  (Fig.  474). 
A  strong  lingual  base-wire  was  anchored  to  the  second  molars,  cus- 
pids, and  incisors  in  the  usual  manner,  excepting  that  the  anchorage 
back  of  the  cuspids  consisted  of  a  curved  wire  extending  from  the 


Fig.  472. 


BACKWARD  MOVEMENT  OF  BICUSPIDS 


401 


base-wire  c,  c.  A  U-shaped  double  spring,  d,  d,  was  attached  to  the 
base-wire  on  each  side  of  the  arch  near  the  molars,  extending  for- 
ward in  a  curve  to  exert  force  on  the  mesial  surfaces  of  the  bicuspids 
from  the  lingual  and  buccal  sides,  the  spring  being  shaped  to  allow 
for  metal  caps  which  were  subsequently  cemented  to  the  bicuspids. 
Action  of  the  si)riiigs  was  caused  by  bending  the  ends  towards  one 
another,  shortening  them  as  required.  When  the  position  or  shape 
of  the  tooth  is  such  that  the  action  of  the  springs  tend  to  elevate 
it,  the  springs  should  be  supported,  either  by  having  the  end  of  one 
or  both  left  sufficiently  long  to  curve  slightly  on  to  the  grinding  sur- 
face, or  by  a  suitably  shaped  clip  soldered  to  the  end  of  one  of  them 
or  to  the  metal  caps  for  that  purpose. 

Fig.  473. 


Supplemental  force  was  applied  to  the  bicuspids  by  means  of  a 
double  cross-bar,  cementing  to  them  on  each  side  of  the  arch  a 
swaged  metal  cap  with  a  wire  eyelet,/,/,  soldered  on  the  bucco- 
distal  surface,  and  utilizing  the  cross-bar  previously  employed  in  the 
upper  arch,  by  hinging  to  it  in  the  same  manner  another  large  wire 
formed  into  a  semicircle  to  follow  the  labio-buccal  curve.  Two  large 
U-shaped  loops  bent  downward  were  arranged  in  the  semicircular 
wire,  one  on  either  side  opposite  the  bicuspids,  with  the  ends 
extending  backward,  e,  e,  to  pass  through  the  eyelets  (/  /)  of  the 
metal-caps ;  the  wire  being  sufficiently  long  to  leave  a  space  about 
one-eighth  of  an  inch  between  it  and  the  front  teeth  when  in  position. 
As  the  bicuspids  moved  backward,  the  semicirclar  wire  approached 

26 


402 


BICUSPIDS 


the  incisors,  and  was  necessarily  lengthened  to  prevent  it  coming  in 
contact  with  them.  This  was  done  by  opening  the  loops  y,  g^  that 
had  been  provided  for  the  purpose.  The  bicuspids  were  moved 
backw^ard  in  a  Hmited  time,  and  when  in  good  position  they  were 
retained  by  cementing  to  them  and  to  tlie  second  molar  on  each 
side  of  the  arch  a  swaged  metal  cap,  with  an  eyelet  on  the  buccal 
surface  (Fig.  475). 

The  incisors  and  cuspids  were  forced  backward  by  adjusting  a 
wire  bar,  /;,  A,  to  follow  the  labio-buccal  surface  near  the  gum,  the 
ends  extending  backward  and  passing  through  the  eyelets  on  the 
caps.     To  this  bar  opposite  the  first  bicuspid   on   each  side   was 

Fig.  474. 


soldered  a  wire  eyelet  for  the  readjustment  of  the  ends  of  the  semi- 
circular wire  of  the  cross-bar  c,  r,  for  causing  supplemental  force  on 
the  teeth ;  and  at  the  same  time  there  was  attached  by  the  eyelets  a 
looped  spring-wire  shaped  to  project  downward,  as  shown  at  t,  i. 
When  the  bar  was  adjusted  in  the  eyelets  of  the  metal-caps  k,  k,  the 
distal  part  or  free  ends  of  the  U-shai)od  loops  were  sprung  back  of 
the  metal  eyelets.  The  bending  together  of  these  spring  loops  a 
little  at  a  time  caused  a  steady,  light  force  inward  on  the  incisors 
and  cus]jids,  without  materially  interfering  with  the  anchorage  teeth, 
and  the  cross-bar  furnished  the  necessary  additional  force  in  the 


Fig.  475. 


Fig.  476. 


BACKWARD  MOVEMENT  OF  BICUSPIDS  403 

same  manner  as  in  moving  backward  the  bicuspids.  The  regulation 
of  the  upper  and  lower  arches  were  completed  about  the  same  time, 
giving  a  good  occlusion.     Fig.  47G  shows  the  improved  condition. 

In  moving  molars  or  bicuspids  distally  in  this  manner,  broad 
collars  cemented  to  the  teeth  can  be  used  in  place  of  the  metal-caps 
by  soldering  to  the  buccal  surface  an  eyelet,  tube,  or  spur  projecting 
forward  about  three-sixteenths  of  an  inch,  to  engage  with  a  cross- 
bar apparatus.  The  direction  of  the  force  for  moving  backward 
bicuspids  and  molars  of  the  lower  or  upper  arch  is  sometimes  better 
controlled  by  an  apparatus  with  an  infralabial  or  a  supralabial  bar 
(Figs.  212  and  240).  It  can  be  used  for  moving  backward  all  of  the 
teeth  of  the  arch,  or,  when  desirable,  for  moving  one  or  more  on 
one  or  both  sides. 


CHAPTER   XXVI 

BICUSPIDS,  TO    MOVE    FORWARD— TO    RELIEVE  IMPACTION— ELE- 
VATE—DEPRESS— ROTATE 

Moving  Bicuspids  Forward  in  the  Line  of  the  Arch. — The 
operator  is  not  often  called  upon  to  move  the  bicuspids  forward, 
but  occasionally  this  change  of  position  is  required, — moving  them 
forward  with  other  teeth  in  cases  of  improper  development  with 
receding  jaw ;  for  correcting  malocclusion  and  closing  objectionable 
interdental  spaces.  The  spaces  may  be  caused  by  migration  back- 
ward of  the  bicuspids,  owing  to  the  injudicious  extraction  of  the 
first  permanent  molars,  or  spaces  may  remain  between  the  cuspids 
and  second  bicuspids  after  the  extraction  of  the  first  bicuspids  to 
give  room  for  the  regulation  of  prominent  incisors  and  cuspids. 
These  conditions  can  be  corrected  by  moving  the  bicuspids  forward 
with  an  apparatus,  or  by  wedging. 

Fig.  477  illustrates  a  device  that  has  been  used  for  moving  the 
bicuspids  forward  and  closing  interdental  spaces.  A  palatine  base- 
wire  is  anchored  with  spring-clasp  attachments  to  the  second  bicus- 
pids. A  spring-wire  is  shaped  into  a  semicircle  to  cross  the  labial 
side  of  the  incisors,  with  a  loop  extending  upward  under  the  lip 
opposite  each  of  the  cuspids ;  the  ends  are  soldered  to  the  spring- 
clasps  on  the  buccal  side  of  the  bicuspids,  by  first  passing  under- 
neath them  a  narrow  piece  of  thin  plate-metal  contoured  similar  to 
a  partial-clasp.  The  second  bicuspids  are  moved  forward  by  gradu- 
ally narrowing  the  loops  in  the  semicircular  spring.  For  closing  an 
interdental  space  at  the  median  line,  a  flat  spring  made  of  a  narrow 
piece  of  spring  plate-metal  is  shaped  to  cross  the  labial  side  of  the 
incisors,  its  ends  curved  backward  to  rest  on  their  distal  surfaces 
and  soldered  in  the  centre  to  the  semicircular  spring.  The  incisors 
are  forced  together  by  curving  the  ends. 

Another  apparatus  for  moving  the  bicuspids  mesially  can  be  made 
by  anchoring  a  base-wire  strongly  to  the  molars,  and  attaching  a 
spring  to  the  base-wire  to  pass  back  of  the  bicuspids,  force  being 
got  by  bending  the  springs  forward.      A  plate  strongly  anchored, 

404 


FORWARD  MOVEMENT  OF  BICUSPIDS 


405 


similar  to  Fig.  470  can  be  utilized,  by  arranging  the  springs  a,  o,  to 
project  back  of  the  bicuspids. 

In  a  receding  upper  jaw,  the  anchorage  is  sometimes  insufficient 
to  move  the  front  teeth  and  the  bicuspids  forward.  In  the  case  of 
Mr.  C,  aged  thirty-eight  years,  these  conditions  were  presented  in 
the  upper  arch.  The  teeth  of  the  lower  arch  were  in  good  position, 
but  the  upper  incisors  and  cuspids  closed  back  of  the  lower  ones, 
interfering  with  mastication  and  presenting  an  unpleasant  appear- 
ance, with  apparent  prognathism.  The  upper  incisors  and  cuspids 
were  first  moved  outward  to  proper  place  and  retained  for  a  time. 
An  apparatus  Avas  then  inserted,  both  to  retain  them  and  to  move 
the  bicuspids  forward.     For  this,  force  was  applied,  but  it  was  soon 

Fig.  477. 


found  that  the  anchorage  teeth  were  moving  backward,  and  finally 
to  such  an  extent  as  to  encroach  on  the  tissues  of  the  cheeks  and 
throat,  causing  serious  inflammation  and  swelling,  and  necessitating- 
a  change  in  the  form  of  anchorage.  None  of  the  teeth  of  the  arch. 
could  be  utilized,  as  all  of  them  had  been  moved. 

Two  sources  of  anchorage  remained  available  ;  the  teeth  of  the 
lower  arch,  and  external  anchorage.  The  upper  bicuspids  were 
separated,  and  an  appliance  was  strongly  anchored  to  the  teeth  of 
the  lower  arch  (Fig.  478).  It  was  made  with  a  lingual  base-wire 
retained  by  spring-clasp  attachments,  and  a  spring  like  a  con- 
tinuous spring-clasp  extending  from  the  base-wire  to  rest  on  the 
labial  faces  of  the  incisors  and  cuspids.  To  the  base-wire  of  the 
appliance,  opposite  the  upper  bicuspids  on  each  side,  was  soldered  a 


406 


BICUSPIDS 


spring-wire,  No.  18  gauge,  bent  into  a  loop  to  project  upward  into 
the  space  back  of  each  of  the  bicuspids  in  occkision,  forming  inclined 
planes.  As  the  loops  were  made  of  spring-wire,  they  yielded  some- 
what to  pressure.  They  were  bent  forward  and  reshaped  from  time 
to  time  to  change  the  force,  moving  the  upper  bicuspids  forward 
rapidly.  Although  the  wire  loops  projected  about  three-sixteenths 
of  an  inch  above  the  grinding  surface  of  the  lower  teeth,  the  patient 

Fig.  478. 


was  able  to  masticate  with  comparative  comfort.  When  this  apparatus 
was  inserted,  the  appliance  was  removed  from  the  upper  arch.  The 
molars  receded  to  their  natural  position,  relieving  the  inflammation; 
after  the  regulating  was  completed,  a  palatine  plate  (Fig.  499)  was 
inserted  as  a  retainer.     A  very  desirable  result  was  obtained. 

I  have  devised  and  used  many  forms  of  apparatus  in  one  arch 
to  cause  the  movement  of  the  teeth  of  the  opposite  arch,  some  of 
which  are  described. 

When  it  is  desirable  to  move  the  bicuspids  or  other  teeth  forward 
bodily,  see  descrijjtion  in  connection  with  Fig.  483.  If  the  usual 
anchorage  is  insufficient,  supplemental  force  can  be  employed.  For 
correcting  the  lower  arch,  see  description  of  apparatus  Fig.  144; 
for  the  upper  arch,  Fig.  373. 

Relieving  Impaction  of  Bicuspids. — When  from  the  too  early  ex- 
traction of  a  deciduous  molar  or  other  cause  the  adjoining  teeth  move 
towards  one  another,  narrowing  the  S{)aco,  it  generally  interferes 
with  the  normal  eruption  of  tlie  bicuspid,  and  if  its  eruption  is  entirely 
arrested  it  is  termed  impaction.     Impaction  of  the  bicuspids  may 


RELIEVING  IMPACTION  OF  BICUSPIDS 


407 


occur  in  either  the  upper  or  lower  arch.  Cases  are  not  infrequent 
where  a  second  deciduous  molar  has  become  impacted  and  is  retained 
in  a  similar  manner  by  tiie  early  eruption  of  the  first  bicuspid,  holding 
the  deciduous  tooth  between  it  and  the  first  permanent  molar  long 
after  tlie  complete  absorption  of  its  roots. 

Fig.  479. 


Fig.  479  shows  a  device  that  Avas  used  for  liberating  an  impacted 
left  upper  bicuspid  for  Miss  C,  aged  fourteen  years.  It  was  made 
by  forming  to  the  inner  curve  of  the  arch  a  lingual  base-wire,  an- 
chored on  the  right  side  to  a  first  bicuspid  and  on  the  left  to  the  first 
molar.     A  spring  was  joined  to  the  base- wire  opposite  the  left  cuspid, 

Fic;.  480. 


and  made  to  extend  in  a  curve  to  the  distal  side  of  the  first  bicuspid. 
The  spring  was  bent  forward  twice  weekly  to  give  force  for  broadening 
the  space,  permitting  the  bicuspid  to  take  a  normal  position. 

In  Fig.  480   is  illustrated  a  modification   of   the  appliance   de- 


408  BICUSPIDS 

scribed,  the  action  of  which  is  hke  a  wedge.  It  is  made  by  forming 
a  single-  or  double-looped  spring  for  the  space,  held  in  place  by 
attaching  the  end  of  one  of  the  loops  to  the  base-wire.  The  spring 
is  elastic,  and  is  suited  to  cases  that  cannot  be  seen  frequently. 

Another  method  that  has  been  used  to  advantage  for  increasing 
the  space  for  an  erupting  second  bicuspid  is  made  by  anchoring  a 
medium-sized  lingual  or  palatine  base- wire  with  a  spring-clasp  attach- 
ment over  the  first  bicuspid  on  either  side  of  the  arch.  One  end  of  a 
spring-wire  bent  into  the  form  of  a  U-shaped  loop  is  soldered  to  the 
pariial-clasp  with  the  base-wire  ;  the  free  end  of  the  spring  is  shaped  to 
extend  into  the  space  in  contact  with  the  mesial  surface  of  the  first 
molar,  the  loop  portion  pointing  towards  the  roof  of  the  mouth. 
Force  is  applied  by  bending  backward  the  spring.  If  the  end  is  not 
well  retained  it  can  be  held  in  position  by  attaching  to  it  a  broad 
partial-clasp  projecting  slightly  onto  the  grinding  surface  of  the  molar. 

In  the  adult,  with  this  form  of  appliance,  it  may  be  necessary  to 
improve  the  anchorage  by  cementing  to  one  or  more  of  the  incisors 
a  collar  with  a  suitably  shaped  lug  to  engage  with  the  base-wire. 

Figs.  159  and  177  illustrate  devices  employed  for  moving  upper 
molars  backward  in  the  line  of  the  arch  to  relieve  impacted  bicus- 
pids, at  the  same  time  moving  the  incisors  outward. 

Elevation  of  Bicuspids. — Elevation  of  the  bicuspids  is  sometimes 
necessary  in  correcting  lack  of  lateral  occlusion  and  for  encouraging 
natural  eruption.  The  latter  procedure  is  especially  for  young  pa- 
tients ;  with  the  adult  the  elevation  of  bicuspids  in  their  sockets  for 
correcting  lack  of  lateral  occlusion  is  not  always  practicable,  as  the 
teeth  are  liable  to  return  to  their  original  position.  Sometimes  the 
process  wastes  away,  and  they  settle  to  a  lower  level  than  before 
operating. 

A  device  for  the  elevation  of  a  bicuspid  may  be  made  by  anchoring- 
a  base-wire  in  the  usual  manner.  Attach  to  it  a  curved  finger-spring 
to  engage  with  a  tube,  hook,  or  pin  on  the  lingual  or  buccal  side 
of  a  collar  that  has  been  cemented  to  the  tooth  to  be  elevated,  sup- 
porting the  apparatus  with  curved  metal  flanges  projecting  from  the 
base-wire  onto  the  adjoining  teeth  to  prevent  it  pressing  on  the  gum 
when  force  is  appHed.  When  this  support  is  required  from  an 
incisor,  plate-metal  should  be  formed  into  a  hook  to  hook  over  the 
morsal  margin.  After  the  teeth  have  been  drawn  to  position  they 
should  be  retained. 


ELEVATION,  DEPRESSION,  ROTATION  OF  BICUSPIDS  409 

For  the  elevation  of  bicuspids,  Dr.  M.  L.  Fay  cements  to  each 
tooth  to  be  elevated  a  sprin^^-dasp  attachment  with  partial  clasps 
arranged  on  the  linyual  and  buccal  sides,  in  this  manner  doing  away 
with  the  adjustment  of  collars,  which,  even  though  thin,  interfere  by 
taking  up  more  or  less  space  in  the  arch.  When  two  or  more 
adjoining  teeth  are  to  be  elevated,  the  spring-clasps  are  made  with 
but  one  arm  extending  over  the  arch,  which  proves  sufficient.  To 
each  partial-clasp  on  the  lingual  and  buccal  sides  are  soldered  hooks 
for  the  adjustment  of  small  rubber  bands  to  pass  over  an  elevating 
bar.  The  bar  is  usually  made  of  three  small  wires  of  German  silver 
united  with  silver  solder.  It  is  arranged  to  pass  over  the  grinding 
surface  of  the  teeth,  and  to  be  supported  by  bending  the  distal  end  at 
an  obtuse  angle  to  rest  on  the  grinding  surface  of  the  second  or  the 
first  molars.  The  front  part  of  the  bar  is  soldered  to  a  swaged 
metal  cap  resting  on  the  incisors,  principally  on  the  lingual  side. 
The  centre  wire  of  the  bar  rests  a  little  higher  than  the  others.  In 
this  notches  are  cut  where  the  rubber  bands  pass  over,  for  protect- 
ing them  in  occlusion.  Dr.  Fay  has  used  the  apparatus  for  elevating 
the  first  lower  molars  and  the  bicuspids  at  one  time. 

For  other  apparatus  suitable  for  the  elevation  of  the  bicuspids,  see 
Incisors,  to  elevate  ;  Cuspids,  to  elevate. 

Depression  of  Bicuspids. — The  bicuspids  are  sometimes  elevated 
in  their  sockets  by  the  eruption  of  adjoining  teeth.  When  extreme 
force  is  applied  for  retracting  the  arch,  the  bicuspids  are  occasionally 
raised  in  their  sockets  by  the  lateral  pressure  on  them,  especially 
when  external  force  is  applied.  Not  infrequently  they  are  elevated 
by  improperly  anchored  regulating  appliances.  When  the  appliance 
is  removed  they  usually  settle  in  their  sockets  again  from  natural 
causes.  If  force  is  required  for  their  depression,  an  appliance  with 
springs  anchored  to  the  adjoining  teeth  is  applicable ;  or  an  appa- 
ratus similar  to  Fig.  345  can  be  utilized ;  or  a  chin-cap  applied  as 
shown  in  Fig.  408. 

Rotation  of  Bicuspids. — Rotation  of  the  bicuspids  requires  more 
force  than  for  rotating  incisors,  but  similar  apparatus  can  be  used. 
For  examples,  see  Figs.  298  and  320. 


CHAPTER   XXVII 

MOLARS,    TO    MOVE    OUTWARD— INWARD— FORWARD— BACKWARD- 
DEPRESS— ELEVATE 

The  molars  in  their  eruption  generally  take  a  good  position  in 
the  arch,  but  sometimes  it  is  necessary  to  depress,  elevate,  or  move 
them  in  a  buccal,  lingual,  mesial,  or  distal  direction. 

Outward  Movement  of  Molars. — Fig.  481  illustrates  the  case  of 
Miss  M.,  aged  fourteen  years.     The  second  right  lower  molar  did 

Fig.  481. 


not  occlude  with  the  teeth  of  the  upper  arch,  but  had  taken  a  posi- 
tion considerably  inside  the  normal  line.  An  appliance  for  its  out- 
ward movement  was  made  with  a  rigid  lingual  base-wire  anchored 
with  spring-clasp  attachments  to  the  first  bicuspids,  and  partial  clasps 
on  the  other  anchorage  teeth.  To  prevent  the  appliance  from  slip- 
ping towards  the  gum,  spurs  were  arranged  to  extend  from  the 
anchorage  portion  onto  the  grinding  surface  of  some  of  the  molars. 
A  small  spring-wire  shaped  to  extend  on  the  lingual  side  of  the 
instanding  molar  was  soldered  to  the  partial-clasp  with  the  base- 
wire.  Force  was  applied  by  bending  the  end  of  the  spring  outward 
from  time  to  time. 

One  or  more  molars  on  each  side  of  the  arch  may  be  moved  out- 
ward, when  required,  with  a  spring  attached  to  an  apparatus  in  this 
maniifr. 

410 


OUTAVARD,  INWARD,  FORWARD  MOVEMENT  OF  MOLARS      411 

When  the  position  of  a  tooth  causes  the  spring  to  slip  towards  ttie 
gum,  or  it  is  not  well  retained,  it  can  be  supported  by  soldering  to 
it  a  short  partial-clasp,  or  a  narrow  piece  of  plate-metal  shaped  to 
project  a  little  onto  the  grinding  surface  of  the  tooth.  The  outward 
or  buccal  movement  of  molars  for  improving  occlusion  is  further 
described  and  illustrated  in  Chapter  IX.,  Expansion  of  the  Denial 
Arch. 

Inward  Movement  of  Molars. — Fig.  482  illustrates  the  case  of 
Miss  W.,  aged  eighteen  years.     The  second  and  third  upper  molars 

Fig.  482. 


did  not  occlude  with  the  lower  molars,  but  had  assumed  a  position 
entirely  outside  of  the  normal  line.  The  first  molars  and  the  bicus- 
pids articulated  well.  For  forcing  the  irregular  teeth  into  position, 
an  appliance  was  made  with  a  rigid  lingual  base- wire  anchored  to  the 
first  molars  and  bicuspids.  A  spring  was  attached  to  the  partial-clasp 
by  the  end  of  the  base-wire  on  each  side  of  the  arch  and  shaped  to 
extend  over  at  the  junction  of  the  second  bicuspid  and  first  molar, 
where  it  was  bent  backward,  terminating  on  the  buccal  surface  of 
those  to  be  moved.  Force  was  applied  from  time  to  time  by  bend- 
ing the  springs  to  press  inward  on  the  irregular  teeth. 

Other  suitable  apparatus  for  moving  molars  inward  is  described  in 
Chapter  X,,  Contraction  of  the  Dental  Arch. 

Forward  Movement  of  Molars. — Owing  to  the  natural  tendency 
of  the  molars  to  move  forward  in  the  line  of  the  arch,  an  apparatus 
is  seldom  employed,  but  its  application  is  occasionally  necessary  to 
close  objectionable  spaces  and  improve  the  occlusion. 


412 


MOLARS 


When  there  are  spaces  in  front  of  the  molars  of  the  upper  arch, 
a  device  similar  to  Fig.  477  is  appUcahle  for  their  movement. 
A  palatine  base-wire  is  anchored  with  spring-clasp  attachments  to 
each  of  the  teeth  to  be  moved.  A  semicircular  spring  with  two 
U-shaped  loops  is  fitted  on  the  labial  side  of  the  front  teeth,  the 
loops  being  placed  opposite  the  first  bicuspids,  with  the  ends 
soldered  to  the  spring-clasps  on  the  buccal  side.  The  closure  of  the 
loops  of  the  spring  gives  the  necessary  force,  but  generally  the 
molars  are  so  firmly  set  in  the  process  that  it  is  advisable  to  apply 
wedges  back  of  them  for  several  weeks  to  encourage  their  move- 
ment. 

Fig.  483  shows  a  device  for  moving  forward  a  lower  or  upper 
molar  on  one  or  both  sides  of  the  arch,  and  for  correcting  molars 

Fig.  483. 


that  are  tipping  forward  by  forcing  them  to  an  upright  position.  To 
each  of  the  molars  to  be  moved  is  fitted  a  strong  broad  collar  with  a 
tube  soldered  horizontally  on  the  buccal  side  near  the  gum.  Another 
short  tube  is  soldered  perpendicularly  to  the  mesio-buccal  surface 
of  the  collar ;  the  end  extending  a  little  above  the  horizontal  tube 
and  in  contact  with  it.  A  swaged  metal-cap  with  a  small  wire  eyelet 
attached  horizontally  on  the  labial  surface  near  the  gum  is  adjusted 
to  the  incisors.  The  cap  is  anchored  by  a  lingual  base-wire  and 
spring-clasp  attachments  passing  over  the  first  bicuspids.  A  spring 
is  shaped  to  enter  the  horizontal  tube  on  the  collar  «,  extending 
forward  and  following  the  curve  of  the  arch  to  the  median  line, 
with  llie  end  bent  at  a  right  angle  to  enter  the  eyelet  c,  of  the 
cap.  Another  spring  of  similar  curve  is  bent  at  a  right  angle  to 
enter  the  perpendicular  tube  on  the  collar  />,  either  from  below  or 
above,   extending   forward ;   both   springs   are  joined    with   solder 


BACKWARD  MOVEMENT  OF  MOLARS  413 

opposite  the  incisors  and  cuspid.  A  similar  combination  spring 
is  applied  when  a  molar  is  to  be  moved  on  tlie  opposite  side  of 
the  arch.  Force  to  juove  the  molar  forward  is  exerted  by  with- 
drawing- the  spring  from  tlie  tubes  a,  6,  and  curving  it  outward 
more  in  the  centre  opposite  the  cuspid  and  first  bicuspid.  The 
hooked  portion  of  the  spring  that  enters  the  eyelet  c  can  be 
curved  more,  or,  for  this  })urpose,  the  portion  of  the  spring  opposite 
the  incisors  may  be  formed  into  a  U-shaped  loop  projecting  down- 
ward. Close  the  loop  a  little  from  time  to  time,  and  readjust. 
For  tipping  the  crowns  to  improve  the  occlusion  and  drawing  the 
roots  forward  bodily,  the  end  of  the  long  wire  at  a,  should  be  bent 
downward,  and  the  short  wire  entering  the  tube  b  bent  more 
acutely  before  its  insertion,  the  spring  being  shortened  as  described 
for  causing  forward  traction  when  required.  If  but  one  molar  is  to 
be  moved  forward  in  this  manner.  It  is  sometimes  advisable  to 
cement  the  cap  to  the  incisors. 

In  moving  the  molars  bodily  forvv^ard,  when  desirable,  supple- 
mental force  can  be  employed  (see  Figs.  144  and  373). 

Backward  Movement  of  Molars. — The  backward  movement  of 
the  molars  is  required  to  give  space  for  impacted  bicuspids,  promi- 
nent bicuspids,  or  cuspids,  for  correcting  the  position  of  malerupting 
third  molars,  and  for  improving  occlusion  ;  sometimes  moving  back- 
w'ard  the  whole  arch. 

Figs,  159  and  454  show  appliances  for  moving  backward  the 
molars  to  relieve  impacted  bicuspids,  the  appliances  being  suitable 
when  there  is  space  back  of  the  first  molars  and  before  the  eruption 
of  the  second  molars.  After  the  eruption  of  the  second  and  the 
third  molars,  supplemental  force  for  moving  them  backward  is  gen- 
erally required,  applied  with  a  cross-bar  similar  to  Figs.  471  and 
474,  or  by  a  chin-cap  and  wire  standards  similar  to  Figs.  212 
and  240. 

For  relieving  an  interlocked  or  impacted  third  molar  (Fig.  484), 
an  appliance  is  made  with  a  lingual  base-wire  well  anchored  to  the 
teeth  on  each  side  of  the  arch.  To  the  base-wire  in  the  distal  part 
is  soldered  a  small  spring  bent  into  a  long  U-shaped  loop  projecting 
towards  the  median  line,  following  the  palatine  curve.  The  free  end 
of  the  spring  is  shaped  like  a  hook,  to  engage  with  the  mesial  sur- 
face of  the  impacted  molar  at  any  point  accessible ;  even  extending 
below  the  gum,  or  shaped  to  project  into  a  pit  provided  in  the  grind- 


414  MOLARS 

ing  surface  of  the  tooth.  Action  is  caused  by  opening  the  loop. 
Forcing  the  tooth  backward  at  tlie  same  time  elevates  it.  The 
appliance  can  be  used  in  either  the  upper  or  the  lower  arch. 

Depression  of  Molars. — The  depression  of  molars  is  required  in 
correcting  lack  of  anterior  occlusion,  and  when  the   molars   have 

Fig.  484. 


been  drawn  from  their  sockets  with  improperly  anchored  regulating 
appliances.  Their  depression  is  usually  accomplished  by  the  con- 
tinued application  of  a  chin-cap  (Fig.  408). 

Elevation  of  Molars. — When  the  incisors  and  cuspids  are  ex- 
truded, the  molars  and  bicuspids  usually  rest  deep  in  their  sockets. 
In  the  process  of  depressing  the  lower  incisors  and  cuspids  all  of 
the  pressure  in  occlusion  is  placed  on  these  teeth  (Fig.  337),  and  the 
molars,  owing  to  their  lack  of  occlusion,  gradually  become  elevated, 
especially  with  young  patients.  The  wedging  of  these  teeth  encour- 
ages their  elevation.  Apparatus  used  for  the  elevation  of  the  bicus- 
pids is  suitable  for  the  elevation  of  the  molars,  but  special  apparatus 
is  seldom  required. 


CHAPTER  XXVIII 

RETENTION    OF    THE    TEETH 

Methods  of  retaining  teeth  after  their  regulation,  and  teeth  loosened 
from  accident,  pyorrhoea  alveolaris,  or  other  cause. 

The  object  of  retention  of  the  teeth  is  to  hold  them  steady  in 
position  until  the  alveolar  process  becomes  sufficiently  recalcified 
about  their  roots  to  properly  sustain  them. 

Not  infrequently  cases  are  presented  that  require  more  skill  in 
retaining  the  teeth  than  for  regulating  them. 

Much  harm  may  arise  from  interrupting  the  retention  of  teeth, 
as  from  the  carelessness  of  the  patient  in  leaving  out  the  appliance 
after  cleansing,  which  leaves  them  without  a  support;  from  the  use  of 
an  imperfect  retaining  device  that  permits  the  teeth  to  move  back  and 
forth  in  their  sockets,  either  of  which  causes  irritation,  interferes  with 
the  normal  deposit  of  bone,  and  may,  when  continued,  result  in  a  thick- 
ening of  the  peridental  membrane,  permitting  a  movement  of  the  tooth  ; 
in  extreme  cases  the  movement  almost  amounting  to  a  false  joint,  and 
finally  causes  the  wasting  away  of  the  alveolar  process  by  absorption. 

The  retaining  device  should  be  made  in  a  manner  thoroughly 
adapted  to  hold  the  teeth  in  their  new  position  without  changing  the 
occlusion  or  interfering  with  enunciation.  It  should  not  be  con- 
spicuous, nor  prevent  the  proper  care  and  absolute  cleanliness  of  the 
teeth.  Especially  is  this  necessary  if  the  retaining  device  is  to  be 
worn  a  considerable  length  of  time.  When  the  teeth  are  moved 
rapidly  in  regulation  the  alveolar  process  is  sprung  more  or  less,  as 
its  absorption  is  necessarily  gradual,  and  generally  on  account  of  this 
the  retainer  needs  to  be  strong  and  the  teeth  retained  a  longer  time 
than  when  moved  more  slowly.  A  strong  retaining  device  is  required 
when  the  occlusion  of  the  teeth  interferes  with  those  being  retained. 
Excessive  force  with  removable  retaining  devices,  sometimes  moving 
the  teeth  too  far,  rotating,  depressing,  or  elevating  them  abnormally 
in  their  sockets,  is  objectionable.  Usually  but  slight  pressure  is  neces- 
sary for  the  retention  of  teeth  that  have  been  moved. 

Length  of  Time  that  Teeth  should  be  retained. — This  is  a  per- 
plexing question  to  the  inexperienced.     No  definite  rule  can  be  laid 

415 


416  RETENTION  OF  THE  TEETH 

down  that  will  include  all  cases ;  but  it  is  almost  always  an  advan- 
tage to  wear  the  retaining  device  a  longer  rather  than  a  shorter 
period.  The  usual  time  ranges  from  four  months  to  a  year.  Long 
retention  of  the  teeth  of  the  young  is  sometimes  required  to  prevent 
them  again  being  moved  out  of  position  by  the  wedging  of  erupting 
teeth  adjoining  them  ;  and  again,  with  persons  of  more  advanced 
years,  it  is  sometimes  necessary  that  the  teeth  be  retained  a  con- 
siderable length  of  time.  Nearly  all  cases  of  expansion  of  the  arch 
require  long  retention. 

It  is  essential  that  the  cause  of  the  irregularity  should  first  be 
removed  when  possible.  If  the  same  influences  that  accompanied 
the  irregularity  are  allowed  to  continue  after  the  removal  of  the 
retainer,  the  teeth  will  usually  return  to  an  irregular  position.  With 
hereditary  tendencies  existing  in  some  instances,  it  is  necessary  that 
the  device  be  worn  continuously  for  several  years,  to  hold  the  teeth 
until  the  bone  and  process  become  thoroughly  calcified  for  their  sup- 
port, and  in  others  worn  indefinitely,  particularly  at  night,  to  accus- 
tom to  the  new  conditions  the  developing  tissues,  the  tongue,  lips, 
and  cheeks.  These  form  a  matrix  which  exerts  a  considerable  influ- 
ence in  shaping  the  jaw  during  its  development.  Their  influence  in 
shaping  the  arch  is  especially  apparent  in  cases  of  mouth-breathing, 
Avhen  an  appliance  for  retaining  the  teeth  does  not  always  prove 
sufficient.  If  the  conditions  that  induce  mouth-breathing  cannot  be 
entirely  removed,  an  apparatus  should  be  employed  to  assist  its  pre- 
vention. Usually  the  application  of  a  properly  constructed  chin-cap 
for  supporting  the  jaw  wdll  be  sufficient  to  establish  nose-breathing 
by  causing  the  lips  to  rest  in  contact,  and  when,  from  excessive  de- 
velopment of  the  alveolar  process  or  extrusion  of  the  teeth  from 
their  sockets,  tlie  jaws  are  separated  to  an  extent  preventing  the 
natural  closure  of  the  lips,  which  is  common  in  these  cases,  the  con- 
tinued use  of  the  chin-cap,  with  properly  directed  force,  will  depress 
the  teeth  in  their  alveoli  and  correct  the  conditions  by  permitting 
the  lips  to  close,  encouraging  nose-breathing.  The  time  required  for 
its  application,  depending  on  the  density  of  the  bone  and  alveolar 
process,  is  shorter  in  the  case  of  the  young. 

Teeth  that  have  been  rotated  generally  need  to  be  retained  a  con- 
siderable length  of  time,  and  it  is  advisable  that  in  their  regulation 
they  be  moved  farther  than  it  is  intended  that  they  shall  remain,  and 
retained  there.    To  prevent  the  tendency  of  the  teeth  to  change  their 


LENGTH  OF  TIME  TEETH  SHOULD  BE  RETAINED    417 

position  after  tlie  removal  of  the  retainer,  it  has  been  suggested  that 
after  they  have  been  rotated  as  far  as  desired,  the  soft  tissue  be 
sejjarated  freely  from  the  neck  of  the  tooth  and  allowed  to  reunite 
in  the  new  location,  de[)ending  on  tlie  cicatrix  thus  formed  to  pre- 
vent their  retrograde  movement. 

There  are  other  conditions,  especially  in  young  patients,  that 
require  no  apparatus  for  retaining  after  regulation,  as  when  the 
upper  incisors  or  cuspids  have  recently  erupted  back  of  tliose  in  the 
lower  arch,  or  when  the  lower  incisors  or  cuspids  have  assmned  a 
position  in  front  of  the  teeth  of  the  upper  arch  ;  either  of  which,  after 
correction,  if  there  is  sufficient  lap,  are  generally  retained  by  their 
natural  occlusion.  Bicuspids  or  molars  that  have  been  moved  back- 
ward, forward,  lingually,  or  in  a  buccal  direction,  are  sometimes 
retained  by  their  occlusion,  the  cusps  of  those  having  been  moved 
fitting  into  the  depressions  and  at  the  junction  of  the  teeth  of  the 
opposite  arch ;  but  in  these  cases  it  is  always  advisable  to  continue 
the  use  of  the  regulating  appliance,  or  to  insert  a  retaining  device  for 
supporting  the  teeth.  Witli  the  bicuspids  or  molars  in  the  adult,  in 
similar  cases,  it  is  sometimes  justifiable  to  reshape  the  surfaces 
of  their  crowns  by  dressing  the  enamel  to  improve  their  planes  of 
occlusion. 

When  it  is  thought  that  the  teeth  have  been  retained  sufficiently 
long,  before  removing  the  retaining  appliance  permanently,  it  should 
be  left  off  for  three  or  five  days,  and  the  teeth  examined  carefully  to 
see  if  there  has  been  any  change  in  their  position.  This  can  usually 
be  determined  by  replacing  the  device.  When  there  has  been  a 
perceptible  change,  it  should  be  w^orn  for  a  longer  time,  otherwise  the 
teeth  should  be  examined  again  in  about  twelve  days,  and  later  at 
stated  intervals,  or  the  appliance  can  be  worn  at  'night. 

Devices  recommended  for  the  retention  of  the  teeth  will  be 
referred  to  as  the  Removable,  Fixed,  and  Pennanent. 

Removable  Retaining  Devices. — Removable  retaining  devices  in- 
clude those  that  can  be  taken  from  the  mouth  by  the  patient  for 
cleansing,  etc.  An  appliance  that  has  been  used  for  the  regulation 
of  the  teeth,  or  made  in  a  similar  manner,  is  often  equally  applicable 
for  their  retention.  Many  styles  of  suitable  apparatus  are  portrayed 
in  the  previous  chapters  in  connection  with  the  regulation  of  the 
teeth.  The  patient  should  be  directed  to  cleanse  the  appliance  and  the 
teeth  thoroughly  at  least  twice  a  day,  in  the  morning  and  at  night. 

27 


418 


RETENTION  OF  THE  TEETH 


Fig.  485  illustrates  a  device  for  retaining  incisors  and  cuspids 
that  have  been  moved  inward.  It  has  a  labio-buccal  bar,  made  by 
shaping  a  wire  to  rest  on  the  teeth,  usually  near  the  gum,  but  some- 
times near  the  incisive  edge.     Its  ends  are  anchored  one  on  either 

side  of  the  arch  with  a  spring- 
clasp  attachment  over  a  bi- 
cuspid or  molar,  having  the 
partial-clasp  on  the  buccal 
surface. 

It  has  been  found  from  ex- 
perience that  one  bicuspid  on 
each  side  of  the  arch  that  has 
not  been  moved  in  regulating 
will  generally  afford  sufficient 
anchorage  for  retaining  six 
front  teeth  that  have  been 
moved  inward. 
In  some  instances,  after  a  retainer  is  applied,  it  is  found  that  a 
better  general  result  can  be  brought  about,  improving  the  occlusion, 
etc.,  by  moving  the  front  teeth  a  little  farther  inward,  and  in  other 
cases  by  letting  them  recede  some  towards  their  original  position. 
When  it  is  apparent  that  any  change  of  this  kind  may  be  needed, 
one  or  more  U-shaped  loops  should  be  formed  in  the  labio-buccal 
bar  (Fig.  486),  with  the  loops 
arranged  to  project  under  the 
lip  on  the  sides  of  the  arch 
where  they  will  be  the  least 
conspicuous,  the  loops  being 
opened  or  closed  by  bending 
to  change  the  hjugth  of  the 
bar  for  causing  more  or  less 
pressure  as  required. 

If  much  inward  traction  is 
needed,  tiio  anchorage  should 
include  one  or  more  molars 
on  each  side  of  the  arch. 

When  preferred,  the  device  can  be  held  by  collars  cemented  to 
the  teeth  (Fig.  487),  the  collars  having  a  tube  soldered  to  the  buccal 
surface  in  a  horizontal  or  in  a  perpendicular  position,  and  the  ends 


Fig.  486. 


REMOVABLE  RETAINING   DEVICES 


419 


of  the  bar  bent  into  the  shape  of  a  hook  for  hooking  into  the  hori- 
zontal tube  in  the  manner  sliown  at  a,  or  bent  at  a  right  angle  to 
pass  into  the  perpendicular  tube,  as  seen  at  6.  The  loops  projecting 
under  the  lip  should  be  made  rather  small  and  properly  adjusted. 

With  this  style  of  retaining  device,  occasionally  more  force  than 
necessary  is  exerted,  which  is  objectionable.     When  too  much  force 

Fir,.  4R7. 


is  applied  to  the  upper  incisors,  it  will  crimp  them;  or  if  in  occlusion 
they  rest  against  those  of  the  lower  arch,  they  are  moved  outward, 
which  necessarily  causes  excessive  forward  traction  on  the  teeth 
used  for  anchorage.  This  device  is  used  for  moving  front  teeth 
inward  by  placing  collars  on  the  molars. 

The  labio-buccal  bar,  with  a  loop  on  either  side,  is  used  in  connec- 
tion with  a  lingual  or  a  palatine  base-wire  for  the  regulation  or 
retention  of  the  teeth  (Fig.   488).     The  distal  ends  of  the  looped 

Fig  4S^ 


portions  are  shaped  to  extend  over  the  arch  at  the  junction  of  two 
of  the  teeth  and  attached  to  the  anchorage.  The  figure  shows  a 
palatine  base-wire. 

Fig.   489  illustrates    a  similar    device    for  retaining   incisors,   or 
incisors  and  cuspids  made  without  the  adjustable  loops  in  tlie  bar. 


420 


RETENTION  OF  THE  TEETH 


A  lingual  base-wire  is  anchored  to  two  or  more  teeth  on  each  side 
of  the  arch  witli  partial-clasps  and  spring-clasp  attachments.     A  bar 

Fig.  489. 


is  shaped  to  rest  on  the  labial  faces  of  the  incisors  usually  near  the 
gum,  and  the  ends  are  passed  directly  over  tlie  arch  just  in  front  or 
back  of  the  cuspids  to  be  soldered  to  the  base-wire. 

When  incisors  have  been  rotated,  their  retention  with  this  device 
can  be  made  more  complete  by  shaping  to  their  lingual  surfaces  a 
continuous  partial-clasp,  attaching  it  to  the  base-wire. 

Fui.  490. 


Fig.  490  illustrates  a  device  with  a  T  for  retaining  corrected 
prominent  upper  incisors,  the  major  part  being  arranged  inside  of 
the  arch.  It  is  made  by  first  uniting  a  small-sized  lingual  base- wire 
with  a  palatine  base-wire,  and  anchoring  tlicm  with  partial-clasps 


REMOVABLE  RETAINING  DEVICES 


421 


and  spring-clasp  attachments.  Tlie  T  is  usually  made  by  fitting  a 
short  bar  of  niotal  to  tlie  labial  side  of  the  incisors  to  be  retained. 
To  the  centre  of  the  bar  is  soldered  another  short  bar  that  is  flattened 
sufficiently  to  pass  between  the  teeth.  The  other  end  is  united  with 
solder  to  the  lingual  base-wire.  Sometimes  the  T  is  made  by  attach- 
ing to  the  base-wire,  side  by  side,  two  thin  narrow  strips  of  spring 
plate-metal  to  pass  between  the  incisors,  with  the  ends  curved  out- 
ward to  rest  on  their  labial  faces. 

Similar  T's  anchored  with  a  rubber  plate  have  been  in  use  for 
many  years. 

Fig.  491  illustrates  a  device  used  for  forcing  outward  an  instanding 
incisor,  and  at  the  same  time  drawing  inward  a  prominent  incisor 

Fig.  491. 


that  was  overlapping  it,  the  same  device  being  used  afterwards  to 
retain  them.  It  was  made  of  wire,  one  end  being  bent  into  the  form 
of  a  continuous  spring-clasp  for  anchorage,  extending  around  a  molar 
and  a  bicuspid  near  the  gum,  passing  over  the  arch  at  the  junction 
of  two  of  the  teeth,  and  the  end  soldered  to  the  body  of  the  wire. 
The  other  end  was  shaped  to  extend  forward,  following  the  lingual 
curve  of  the  arch,  passing  back  of  the  instanding  incisor,  through 
the  interdental  space  at  the  median  line,  and  terminating  in  a  curve 
on  the  labial  face  of  the  prominent  incisor.  The  device  was  removed 
by  pressing  downward  on  the  anchorage  portion,  then  rotating  it  and 
drawing  it  backward  from  between  the  teeth. 

Fig.  492  illustrates  a  device  used  for  moving  into  line  and  retaining 
a  prominent  incisor.  A  lingual  base-wire  is  anchored  with  partial- 
clasps  and  spring-clasp  attaclnnents.    A  spring-wire  shaped  to  extend 


422 


RETENTION   OF  THE  TEETH 


over  the  arch  at  the  junction  of  the  incisors,  with  the  end  bent  at  a 
right  angle  to  rest  on  the  labial  side,  is  soldered  to  the  base-wire 

FiCx.  492. 


Fig.  493 


near  the  median  line.     Two  or  more  springs  of  this  shape  may  be 
used,  or  a  continuous  spring  employed  (Figs.  223-225). 

When  one  or  two  incisors  have  been  moved  outward  or  inward 
to  line  and  need  to  be  retained  but  temporarily,  they  can  sometimes 
be  sufficiently  supported  with  a  small-sized  wire  ligature  of  platinum, 
silver,  or  copper,  passing  it  back  or  in  front  of  them  as  need  be  and 
around  the  adjoining  teeth  when  they  are  in  good  position,  drawn 
tight,  and  the  ends  fastened.  When  the  centrals  have  not  been 
moved,  the  laterals  can  be  retained  by  fastening  a  ligature  to  them 
in  a  similar  manner. 

Fig.  493  shows  a  simple  device  that  was  worn  by 
Miss  B.  for  four  years  for  supporting  a  right  upper 
central  incisor  that  had  been  rotated. 

As  the  torsion  was  hereditary,  it  was  known  that  the 
retainer  would  need  to  be  worn  a  long  time.  A  narrow  strip  of 
spring  gold-plate  was  bent  in  the  form  of  a  clasp  to  surround  the 
tooth,  with  one  end  resting  on  the  labial  face,  and  the  other  end  bent 
outward  to  rest  on  the  labial  face  of  one  of  the  adjoining  teeth.  A 
spur  was  attached  with  solder  to  the  lingual  side  for  projecting  onto 
the  surface  of  the  other  adjoining  tooth.  Being  made  in  this  manner 
it  was  less  conspicuous  than  a  collar  would  have  been.  When  pre- 
ferred, iKjth  ends  may  clasp  the  tooth. 

A  similar  device  can  be  made  to  retain  two  or  more  teeth  by 
joining  two  clasps  and  cementing  them  to  place. 


REMOVABLE  RETAINING   DEVICES  423 

Fig.  494  illustrates  a  plate  with  a  labio-buccal  bar  for  retaining 
six  anterior  teeth.  It  is  made  with  rubber  covering  the  roof  of  the 
mouth  and  fitted  well  to  the  necks  of  the  teeth.  A  semicircular  wire 
is  shaped  to  pass  in  front  of  the  incisors  and  cuspids  near  the  gum, 
the  ends  being  curved  to  extend  over  the  arch  usually  at  the  junction 
of  the  cuspid  and  first  bicuspid  to  be  embedded  in  the  vulcanite.  If 
the  plate  interferes  with  the  tongue  in  enunciation,  in  some  cases  the 
front  part  can  be  cut  away ;  but  for  retaining  teeth  that  have  been 
crimped  or  rotated,  as  in  the  V-shaped  arch,  the  rubber  should  cover 
the  whole  palatine  surface,  resting  in  contact  with  all  of  the  teeth, 
and  the  bar  should  cross  the  labial  side  of  those  to  be  retained  ratlier 
near  their  incisive  edge. 

Fig.  494. 


With  this  form  of  retaining  plate  it  is  generally  an  advantage  to 
have  the  labio-buccal  bar  adjustable  for  causing  more  or  less  force 
as  the  case  requires.  This  is  accomplished  by  arranging  in  the  bar, 
on  one  or  both  sides  of  the  arch,  a  small  U-shaped  loop  (a,  a),  which 
can  be  opened  or  closed  by  bending.  I  have  also  used  this  form  of 
bar  in  connection  with  a  plate  many  years  for  the  regulation  of  teeth. 

When  there  is  insufficient  space  for  the  wire-bar  to  pass  be- 
tween the  bicuspids  and  cuspids  it  should  be  curved  up  well  over 
their  coronal  surface,  as,  if  the  teeth  have  been  drawn  together,  and 
the  wire  is  permitted  to  rest  heavily  at  this  point,  it  will  gradually 
wedge  the  teeth  apart  again. 

A  round  wire  for  the  bar  is  generally  preferable  to  the  half-round 
or  flat.     It  can  be  bent  more  readily  into  form,  and,  being  round, 


424  RETENTION  OF  THE  TEETH 

it  lias  less  surface  contact  with  the  teeth,  and  is  not  so  liable  to 
retain  the  secretions  and  food-particles,  thus  lessening  the  tendency 
to  decay.  The  plate  may  be  retained  by  a  suction  chamber,  by 
wire-clasps  or  plate-clasps  extending  around  the  distal  molars  in 
the  arch,  or  by  spring-clasps  passing  over  the  bicuspids  or  molars. 

I  have  devised  and  used  successfully  a  great  variety  of  spur  and 
spring  attachments  in  connection  with  metal  and  vulcanite  plates  for 
retaining  as  well  as  for  moving  the  teeth  in  different  parts  of  the 
arch.  Incisors  that  have  been  moved  laterally  tow^ards  or  from  each 
other  may  be  retained  with  metal  points  extending  from  a  plate  or  a 
base-wire  into  the  interdental  spaces  either  side  of  them.  Teeth 
that  have  been  rotated  can  be  retained  in  the  same  manner  where 
there  are  interdental  spaces  by  having  the  metal  points  project 
through  or  over  at  their  junction  and  terminate  in  a  curve  in  front 
of  them. 

For  retaining  upper  incisors  that  have  been  too  prominent  and 
depressed  in  their  alveoli,  sheet-metal  can  be  shaped  and  attached  in 
the  front  part  of  the  plate  in  a  manner  to  pass  over  the  incisive 
edge  and  rest  on  the  labial  side  of  them  without  interfering  with  the 
occlusion. 

Bicuspids  that  have  been  moved  forward  or  backward  may  be 
retained  with  a  flat  or  round  metal  spur  projecting  from  a  plate,  or 
the  plate  may  be  made  to  extend  into  the  space. 

In  some  instances  it  is  an  advantage  to  have  the  projecting  portion 
between  the  bicuspids  sufficiently  thick  from  above  downward  to 
extend  to  the  coronal  surface,  so  that  in  occlusion  the  teeth  of  the 
lower  arch  will  rest  against  it,  affording  an  additional  means  of  hold- 
ing the  plate  in  place. 

Metal  'plates  can  be  used  for  retaining,  as  for  regulating,  anchored 
when  desired  by  a  suction,  clasps,  springs,  etc. 

Fig.  495  illustrates  a  wire  retaining  device,  which  in  1887  I  de- 
scribed and  termed  a  "crib,"  (See  Dental  Cosmos,  1887,  page  375.) 
It  was  used  to  retain  teeth  of  the  lower  arch  after  its  expansion,  for 
the  purpose  of  admitting  instanding  lateral  incisors,  with  apparatus 
as  illustrated.  The  arch  was  expanded  and  the  teeth  regulated 
in  the  manner  shown  in  Figs.  141  and  142.  The  retaining  device 
was  made  of  round  })laliiio-iri(liuiii  wire  shaped  to  clasp  the  teeth 
on  the  labial  and  lingual  sides,  extending  around  the  entire  arch. 
It  was  formed  to  a  plaster  model,  starting  at  a  given  point  on  the 


REMOVABLE   RETAINING   DEVICES  425 

lingual  surface  of  the  molars,  following  the  line  of  the  gum  and 
making  sure  that  the  part  fitted  was  held  in  the  same  relation- 
ship and  not  allowed  to  slip.  The  wire  was  bent  sharply  by  the 
fingers   and  clasp-benders    to   clasp   the    necks    of   the    teeth,    con- 

FiG.  495. 


tinning  to  the  starting-point.  The  ends  were  soldered  with  pure 
gold.  The  appliance  was  strengthened  and  prevented  from  pressing 
on  the  gum  by  connecting  the  labial  and  lingual  wires  at  different 
points  of  the  arch  with  short  pieces  of  similar  wire  material, 
arranged  to  pass  over  the  coronal  surface  at  the  junction  of  two 
of  the  teeth  and  soldered.  It  was  further  stiffened  by  soldering 
to  the  lingual  side  an  additional  wire  bent  into  two  partial  U-shaped 
loops  located  to  project  downward  back  of  the  lateral  incisors.  The 
appliance  with  this  and  other  spring  attachments  has  been  used  for 
the  regulation  of  the  teeth. 

Sometimes  the  conditions  require  the  wire  to  be  extended  around 
only  a  portion  of  the  arch,  following  the  line  of 'the  gum  and  passing 
over  at  the  junction  of  the  teeth  at  any  place  the  occlusion  will 
permit.  Fig.  496  shows  a  device  made  in  this  manner  for  retaining 
the  teeth  of  the  upper  arch  after  expansion  and  the  movement  out- 
ward of  an  instanding  lateral  incisor  (Figs.  198  and  199).  The 
labial  and  lingual  wires  were  connected  with  only  one  bar,  which 
was  flat  and  passed  between  the  central  incisors.  This  form  of 
device  is  applicable  for  retaining  prominent  teeth  that  have  been 
corrected  in  the  upper  or  lower  arch. 

Under  the  conditions  of  this  and  the  previous  case,  a  lingual  base- 
wire,  with  springs  properly  anchored,  or  a  plate,  is  applicable. 


426 


RETENTION   OF  THE  TEETH 


Many  years  ago  Dr.  Richardson  described  an  appliance  for  retain- 
ing the  teeth  of  the  lower  arch.  It  was  made  of  vulcanite,  extend- 
ing on  the  labio-buccal  and  lingual  sides  of  the  teeth,  and  passing 
between  some  of  them  and  back  of  the  last  molars,  leaving  the 


Fig.  496. 


crowns  exposed.  In  other  cases  the  rubber  on  the  labial  and 
lingual  sides  Avas  united  with  pieces  of  metal  anchored  in  the  vul- 
canite, being  shaped  to  extend  through  interdental  spaces.  When 
there  are  no  spaces,  the  metal  can  pass  over  the  grinding  surface  at 
the  junction  of  two  of  the  teeth. 

In  Fig.  497  is  shown  a  similar  device  made  of  metal,  which  owing 
to  its  weight  is  less  liable  to  become  displaced.     It  can  be  made  by 

Fig.  497. 


fitting  partial-clasps  to  the  teeth,  and  passing  several  U-shaped 
pieces  of  wire  over  the  arch  at  different  points  to  connect  the  outer 
and  inner  parts.  Other  wires  can  be  passed  around  the  distal 
molars  when  desired. 


REMOVABLE  RETAINING   DEVICES 


427 


The  parts  are  united  witli  soft  solder,  using  a  considerable  amount 
of  it,  or  by  castinf,--  fusible  metal  in  a  mould,  using  a  correct  plaster 
model.  For  casting,  form  a  wax  try-plate  on  the  labial  and  lingual 
sides  of  the  teeth  covering  the  ends  of  the  wires.  Then  take  an 
impression  with  mouldine,  or  plaster,  after  which  the  try-plate  is  to 
be  removed,  and  the  mouldine  or  plaster  replaced,  forming  a  matrix. 
An  aperture  for  pouring  the  heated  metal  is  made  by  inserting  a 
small-sized  metal  fumiel,  tliree  or  four  inches  long,  into  the  mould 
opposite  the  last  molar  in  the  arch  on  one  side ;  a  small  vent-hole 
is  made  opposite  the  last  molar  on  the  other  side  of  the  arch.  The 
mould  is  then  well  dried  out,  heated,  and  the  metal  poured,  sur- 
rounding the  ends  of  the  wires  and  uniting  the  parts  of  the  appliance. 
Enough  metal  should  be  used  to  fill  both  the  mould  and  the  funnel. 
The  higher  the  metal  rises  in  the  funnel,  the  more  i)ressure  is  caused 
for  distributing  the  metal  in  the  mould,  thus  insuring  a  sharp  cast. 
The  appliance  is  finished  in  the  same  manner  as  a  cast  metal  plate. 

Fig.  498  shows  a  device  that  is  serviceable  for  retaining  the 
teeth  of  either  the  upper  or  lower  arch  after  expansion,  or  for  sup- 

FiG.  498 


porting  one  or  more  that  have  been  moved  outward  or  rotated.  A 
lingual  base-wire  is  fitted  well  and  anchored  by  spring-clasp  attach- 
ments, and  partial-clasps  usually  on  all  of  the  teeth. 

When  the  device  is  to  be  used  for  retaining  incisors,  especially 
in  the  upper  arch,  it  is  advisable  to  cement  to  one  or  more  of  them 
a  collar  with  a  lug  on  the  lingual  side  to  engage  with  the  base-wire 
for  retaining  that  part.     The  lug  should  always  project  at  a  right 


428  RETENTION   OF  THE  TEETH 

angle  with  the  long  axis  of  the  tooth,  or  curve  somewhat  towards 
the  neck,  and  at  an  obtuse  angle,  as  with  the  latter  shape  tlie  tooth 
is  likely  to  move  forward  and  the  lug  become  disengaged  from  the 
retaining  device. 

After  expanding,  or  moving  outward  one  or  more  of  the  incisors 
of  the  upper  arch,  a  palatine  rubber  plate  is  suitable  for  retaining 
(Fig.  499).  The  plate  is  generally  held  firmly  enough  by  fitting  it 
carefully  to  the  necks  of  the  teeth.     In  some  conditions,  it  is  ad- 

FiG.  499. 


visable  to  have  the  j^late  provided  with  suction,  or  with  one  or  more 
spring-clasps  extending  from  the  rubber  on  either  side  to  clasp  a 
bicuspid  or  molar. 

Incisors  that  have  been  moved  outward,  especially  those  that  have 
been  elevated,  can  generally  be  best  retained  by  cementing  to  each 
of  them  a  collar  with  a  lug,  the  lug  being  suitably  .shaped  to  hook 
over  the  edge  of  the  plate  or  base-wire.  A  skeleton  plate  can  be 
utilized  in  this  manner,  and  when  necessary  made  firmer  by  cement- 
ing a  collar  with  a  lug  to  a  bicuspid  or  a  molar  on  each  side  of  the 
arch,  the  lug  being  shaped  to  project  slightly  over  the  edge  of  the 
plate. 

After  expansion  of  the  arch,  especially  in  cases  of  mouth-breathing, 
it  is  generally  advisable  to  apply  a  chin-cap  for  improving  the  occlu- 
sion. It  should  be  worn  regularly  at  night,  and  more  or  less  during 
the  day  in  some  cases. 

Fixed  Retaim.ng  Devices. — Fixed  retaining  devices  are  usually  in 
the  form  of  a  collar  or  a  cap,  with  suitable  attachments,  and  properly 
cemented  to  the  teeth.  They  are  generally  more  conspicuous  than 
the  removable  devices,   but  are   comfortable  to  tlie  patient.     The 


FIXED  RETAINING  DEVICES 


429 


cement  is  liable  to  wear  away,  and  an  examination  should  be  made 
at  regular  intervals  to  see  that  there  is  no  wasting  away  of  the  cement 
from  under  the  retainer.  Repair  it  w-hen  necessary  to  prevent  the 
accumulation  of  food  or  secretions  which  would  decompose  and 
cause  decay  of  the  tooth. 

In  retaining,  it  is  essential  that  the  tooth  be  held  absolutely  firm. 
It  can  be  supported  by  fitting  accurately  to  it  a  thin  collar,  to  which 
is  soldered  a  spur  or  bar,  projecting  onto  either  the  labial  or  the 
lingual  surface  of  one  or  both  adjoining  teeth  in  such  a  manner  as 
to  prevent  it  from  returning  to  its  original  position. 

When  the  occlusion  will  permit,  and  other  conditions  are  favor- 
able, the  spur  should  be  arranged  on  the  lingual  side,  it  being  less 
conspicuous. 

Fig.  500  illustrates  the  case  of  Mr.  N.  The  left  upper  central  and 
lateral  incisors  were  twisted  outward,  lapping  one  another  as  in  the 

Fig.  500. 


V-shaped  arch.  A  first  bicuspid  was  extracted  to  gain  space  for 
their  correction.  The  incisors  were  rotated  to  position,  and  retained 
by  cementing  to  each  a  collar  with  a  spur  projecting  onto  an  adjoin- 
ing tooth,  the  spur  from  the  lateral  resting  on  the  labial  side  of  the 
cuspid,  and  the  one  from  the  central  resting  on  the  labial  side  of  the 
collar  on  the  lateral.  To  prevent  the  left  central  incisor  from  moving 
outward,  another  spur  was  soldered  to  the  lingual  side  of  the  collar, 
being  shaped  to  project  back  of  the  adjoining  central. 

Two  spurs  attached  to  a  collar,  one  projecting  from  the  lingual 
and  the  other  from  the  labial  side,  in  this  manner,  are  generally 
required  for  retaining  corrected  cases  of  extreme  torsion.  The  spur 
should  always  be  strong  and  well  soldered.    Make  it  of  spring  plate- 


430 


RETENTION  OF  THE  TEETH 


metal,  lialf-round  or  round  wire,  lapping  well  on  the  collar ;  other- 
wise the  collar,  if  thin,  is  liable  to  stretch. 

A  retaining  collar  with  one  spur  can  sometimes  be  made  to 
advantage  by  fitting  the  metal  to  the  tooth  in  such  a  manner  that 
the  lap  will  be  on  the  side  where  the  spur  is  required,  leaving  the 
ends  long,  shaped  to  rest  together,  and  soldered,  after  which  the 
projecting  part  can  be  made  narrow.  When  the  retaining  device  is 
to  be  worn  a  considerable  length  of  time,  the  part  of  the  spur  that 
rests  in  contact  with  the  adjoining  tooth  should  be  formed  into  a 
point,  the  spur  being  made  small  and  bent  forward  slightly,  or  a 
point  made  by  flowing  on  to  it  a  small  ball  of  solder.  Otherwise, 
the  spur,  being  left  flat,  and  covering  a  considerable  surface  of  the 
tooth,  is  liable  to  retain  the  secretions  and  cause  decay. 

The  three  following  devices  are  recommended  by  Dr.  Guilford  :  * 
For  retaining  two  central  incisors,  or  a  central  and  lateral  that  have 
been  rotated,  two  platinum  or  gold  collars,  properly  fitted  and  united, 
as  seen  in  Fig.  501,  are  firmly  cemented  on  the  teeth.     A  gold-bar 

Fig.  503. 
Fig.  501.  Fig.  502. 


Fig.  604. 


or  Spur  attached  to  the  labial  or  lingual  side  of  one  or  more  collars, 
so  as  to  project  onto  the  adjoining  teeth,  as  shown  in  Figs.  502  and 
503,  is  utilized  for  retaining  teeth  after  rotation,  and  for  preventing 
them  from  moving  out  of  the  circle  after  their  correction,  especially 

when  the  teeth  of  the  opposite  arch  rest 
heavily  against  it.  Sometimes,  to  make  the 
retainer  less  conspicuous,  a  portion  of  the 
front  of  the  collar  can  be  dressed  away. 

In  Fig.  504  is  illustrated  a  similar  device 

for  retaining  a  cuspid  that  has  been  moved 

outward.    A  collar  is  accurately  fitted  to  the 

tooth,  and  a  spur  or  bar  soldered  to  the  labial  side  of  the  collar,  with 

the  ends  shaped  to  rest  on  the  adjoining  teeth. 

A  collar  with  a  tube  attached  to  the  labial  or  lingual  side  has  been 
found  an  effective  and  convenient  method  of  retaining  after  rotation, 


*  Guilford's  Orthodontia,  1898,  p.  91. 


FIXED   RETAINING  DEVICES 


431 


by  passing  through  the  tube  a  wire-bar.  Two  incisors  can  be  retained 
in  the  same  manner  by  cementing  a  collar  with  a  tube  on  each. 
(Several  figures  showing  collars  with  tubes  suitable  for  retaining  will 
be  found  in  Chapter  XIV.,  Incisors,  To  rotate.)  This  means  of 
anchorage  has  been  employed  for  retaining  incisors  after  being  moved 
laterally  together,  by  inserting  a  headed  pin  and  btmding  the  end 
downward  sufficiently  to  prevent  its  withdrawal. 

In  Fig.  505  is  shown  a  device  that  was  employed  for  retaining  a 
partially   erupted  upper  lateral  incisor  that  had  been  moved  out- 

FiG.  505. 


Fig.  506. 


ward  from  a  lingual  occlusion.  The  lateral  had  been  pressed  inward 
by  a  non-erupted  cuspid.  The  tooth  was  not  long  enough  to  be 
retained  by  the  natural  lap  in  occlusion,  and  a  collar  with  a  flange  on 
the  lingual  side,  as  seen  at  «,  was  cemented  to  it,  the  flange  being 
made  of  plate-metal  shaped  to  project  downward,  and  sufficiently 
long  to  close  in  front  of  the  lower  teeth.  This  part  of  the  metal 
was  dressed  away  from  time  to  time  as  the 
tooth  became  more  fully  erupted. 

After  broadening  the  space  for  a  non- 
erupted  cuspid  or  bicuspid,  it  is  generally 
important  that  the  space  be  preserved  to 
encourage  its  eruption.  A  device  for  this 
purpose  is  shown  in  Fig.  506.  A  collar  is 
fitted  to  one  of  the  adjoining  teeth,  and  a 
partial-clasp  or  collar  to  the  other,  to  which 

the  ends  of  a  wire  bent  into  a  partial  U-shaped  loop  are  soldered 
and  the  device  cemented  to  place. 

Teeth  that  have  been  regulated,  or  teeth  that  have  become  loosened 
from  pyorrhoea  alveolaris,  from  accident,  or  other  cause,  can  be  re- 


432 


RETEXTION   OF  THE  TEETH 


tained  by  cementing  to  them  a  metal  cap  (Figs.  507  and  508).  The 
cap  should  be  swaged  with  accurate  dies  in  form  to  pass  over  the 
teeth,  either  covering  them  entirely,  extending  to  the  margin  of  the 
gum,  or,  where  the  conditions  will  permit,  it  may  be  made  less  con- 


FiG.  508. 


Fig.  509. 


spicuous  by  covering  only  a  portion  of  the  labial  and  lingual  sides. 
When  the  teeth  are  very  loose  the  cap  should  usually  include  two  or 
more  adjoining  teeth  that  are  firm  in  their  sockets. 

Fig.  509  shows  a  gold-cap  that  was  used  to  retain  four  upper 
incisors  that  had  been  moved  bodily  outward,  and  the  cuspids  that 

were  too  prominent  and  had  been 
moved  into  the  circle  of  the  arch. 
(For  method  of  making  cap,  see  page 
92.)  A  cap  made  in  this  manner  is 
occasionally  recjuired  for  retaining 
lower  incisors.  It  is  especially  de- 
sirable in  cases  where  the  lower  in- 
cisors have  been  forced  outward,  carrying  with  them,  by  their  pressure 
in  occlusion,  in.standing  upper  teeth. 

In  such  a  case  the  pressure  of  the  upper  incisors  against  the  lower 
ones  is  so  great  that  the  ordinary  retainer  is  not  always  sufficient  for 
supporting  them  in  good  position.  It  is  also  advantageously  used 
for  retaining  the  line  of  the  lower  incisors  when  forcibly  contracting 
the  anterior  upper  arch.  The  excessive  inward  pressure  of  the  upper 
incisors  against  the  lower  ones  when  not  supported  is  liable  to  crimp 
them.  The  cap  can  also  be  utilized  for  retaining  cases  of  corrected 
extrusion  or  retrusion  of  the  teeth. 

I  have  in  many  instances  made  similar  caps  of  German  silver  and 
of  platinoid,  uniting  the  parts  with  silver  or  gold  solder.  These 
metals  are  harder  to  swage,  but  are  sometimes  less  conspicuous  than 
gold,  and  generally  when  they  are  kept  well  jjolished  their  oxidation 
does  not  become  ol)jectiona])le.  A  cap  covering  the  teeth  (Fig.  510), 
with  a  projecting  shoulder  swaged  or  soldered  on  the  liiif^ual  side  (a), 
Avas  used  for  depress! n.L'-  I  lie  lower  and  upper  incisors  and  retaining 
them.     (For  description  of  a  similar  case,  see  page  322.) 


FIXED   RETAINING  DEVICES  433 

A  shoulder  curved  downward  in  the  form  of  an  inverted  trough  is 
also  utiUzed  for  preventing  abnormal  occlusion.  The  lap  of  the  teeth, 
when  excessive,  can  sometimes  be  controlled  by  attaching  a  trough 
to  the  labial  side  of  a  cap  cemented  to  the  lower  incisors  and  cuspids. 

Extruding  lower  incisors  can  be  driven  downward  and  retained 
by  a  plate  covering  the  i)alatine  arch,  made  as  shown  in  Fig.  337. 

A  fixed  device  with  a  labio-buccal  bar  that  has  been  in  general 
use  for  many  years  is  illustrated  in  Fig.  511.  It  was  utilized  for 
retaining  six  front  teeth  of  the  upper  arch   that   had   been  moved 

Fig.  510. 

Fig.  511. 


inward,  the  first  bicuspids  having  been  extracted.  Thin  gold  collars 
were  fitted  to  each  of  the  second  bicuspids,  and  a  bar  of  half-round 
gold-wire  was  formed  accurately  to  the  labial  side  of  the  teeth  to  be 
retained,  the  ends  crossing  the  collars  near  the  gum  and  soldered. 
The  collars  were  then  cemented  to  the  bicuspids,  and  three  of  the 
incisors  that  had  been  rotated  were  bound  to  the  bar  with  ligatures 
of  wire. 

Gold  crowns  and  clasps  have  been  used  in  place  of  collars  for 
anchorage.  A  removable  appliance  anchored  with  spring-clasp  at- 
tachments (Fig.  486)  is  usually  preferable,  as  the  teeth  and  appliance 
can  be  kept  more  cleanly. 

In  Fig.  512  is  illustrated  a  fixed  retainer  with  a  lingual  base-wire 
for  supporting  four  or  six  front  teeth  that  have  been  moved  outward. 
At  the  same  time  an  attachment  can  be  added  at  the  median  line 
for  retaining  one  or  more  central  incisors  that  have  been  rotated.  A 
collar  is  adjusted  to  each  of  the  cuspids  or  first  bicuspids,  and  a 
stiff  round  or  half-round  wire  fitted  to  the  lingual  side  of  the  incisors, 
with  the   ends  soldered  to  the  collars.     For  retaining  the  rotated 

28 


434 


RETENTION  OF  THE  TEETH 


incisors  a  short  piece  of  wire  is  soldered  to  the  centre  of  the  base- 
wire  ;  it  is   shaped   to  pass  over  the  arch  at  the  junction  of  tlie 

Fig.  512. 


Fig.  513. 


incisors.  The  end  is  bent  approximately  to  a  right  angle  to  rest  on 
the  labial  side,  being  arranged  to  retain  one  or  two  teeth.  Some- 
times in  retaining  two  incisors  it  is  preferable  to  attach  with  solder 
underneath  the  outer  end  of  the  wire  a  piece  of  plate-metal  to  cross 
the  labial  side.  When  desirable,  two  or  more  attachments  of  this 
character  can  be  extended  from  the  base-wire. 

In  Fig.  513  is  shown  a  device  employed  for  the  retention  of  a 
first  bicuspid  that  had  been  elevated.  A  collar  was  fitted  to  the 
bicuspid,  to  which  it  was  finally  cemented.  To  the 
mesial  surface  of  the  collar  was  soldered  a  piece  of 
plate-metal,  from  the  front  edge  of  which  was  cut  a 
deep  U-shaped  groove,  leaving  projecting  arms  to 
embrace  the  labial  and  lingual  side  of  the  cuspid 
above  the  cingulum.  To  the  distal  side  of  the  collar 
was  soldered  a  wire-arm  projecting  backward  to  rest 
on  the  grinding  surface  of  the  second  bicuspid.  Two 
arms  of  wire,  properly  shaped  and  soldered  to  the 
mesial  surface  of  the  collar,  would  have  the  advantage 
of  being  equally  strong  and  less  bulky. 
Permanent  Retaining  Devices. — Permanent  retaining  devices  gen- 
erally consist  of  an  excessively  contoured  gold  filling,  a  metal  spur, 
a  bar,  a  crown,  or  a  bridge  attached  to  one  or  more  of  the  teeth. 
The  permanent  retention  of  teeth  is  occasionally  required  to  prevail 
over  hereditary  tendencies,  to  retain  teeth  that  have  been  rotated, 


PERMANENT  RETAINING  DEVICES 


435 


to  maintain  equal  spaces  between  teeth  after  expansion  and  regula- 
tion, and  to  maintain  spaces  caused  by  loss  or  non-eruption  of  teeth. 
A  corrected  torsion  of  the  incisors  in  an  arch  naturally  contracted 
can  in  some  instances  be  permanently  retained  by  bevelling  the 
approximal  surfaces  in  a  suitable  manner  to  rest  under  counter- 
bevelled  surfaces  of  the  adjoining  teeth,  as  shown  in  Fig.  514.  This 
method  was  adopted  in  the  case  of  Mr.  K.,  aged  pj^  5^4 
twenty-four  years.  The  dressing  of  the  surface  of 
the  enamel  was  accomplished  with  a  diamond  disk. 
Care  should  be  exercised  not  to  cut  through  the 
enamel,  but  in  some  conditions  it  may  be  necessary. 
Dressing  of  the  teeth  should  not  be  undertaken  in  the  case  of  young 
patients. 

When  there  is  cavity  in  the  lateral  surface  of  a  tooth  that  has  been 
rotated,  or  in  the  adjoining  tooth,  a  gold  spur  can  be  cemented  into 
the  cavity  in  position  to  permanently  retain  it ;  or  screwed  into  a  hole 
provided  for  it  in  a  filling.  When  there  is  no  cavity,  the  spur  may 
be  screwed  into  a  hole  made  in  the  structure  of  the  tooth.* 

For  retaining  teeth  that  have  been  rotated,  and  for  keeping  space, 
as  between  incisors,  a  filling  of  gold  can  be  inserted  in  a  cavity, 
having  it  excessively  contoured  and  properly 
shaped  for  the  purpose.! 

When  there  are  broad  spaces  between  the 
teeth,  as  is  commonly  seen  with  the  incisors, 
a  permanent  retainer  may  be  applied  after 
their  correction,  in  the  form  of  a  staple  device, 
as  shown  in  Fig.  51 5.  J  A  deep  pit  is  drilled 
in  the  lingual  surface  of  each  of  the  teeth, 
<  avoiding  the  pulp.  A  wire  is  then  bent  twice 
at  right  angles,  forming  a  staple ;  the  ends  are 
roughened  and  cemented  to  place.  Several  teeth  have  been  joined 
in  this  manner.  When  desirable  the  device  can  be  used  for  holding 
teeth  apart.  Dr.  Niles  recommends  a  link  connection,  permitting 
a  more  free  movement  of  the  teeth. 

A  metal-bar  anchored  with  fillings  in  cavities  in  teeth  is  some- 


FiG.  515. 


*  Baker,  Guilford's  Orthodontia,  1898,  p.  93. 
f  Farrar,  Irregularities  of  the  Teeth. 
J  Case,  Dental  Review,  1904,  p.  86. 


436 


RETENTION  OF  THE   TEETH 


times  employed  for  preserving  their  proper  spacing.  "When  the 
space  is  broad,  the  appHcation  of  a  bridge  sustained  by  a  collar  or 
a  crown  cemented  to  one  or  more  of  the  teeth  is  applicable.  A 
removable  plate  has  been  utilized. 

Fig.  516. 


Removable  Bridge. — Fig.  516  shows  a  removable  gold  bridge 
"with  porcelain  front  supplying  a  first  right  upper  bicuspid  that  has 
been  worn  with  comfort  over  eight  years  and  is  still  doing  good 
service.  It  is  held  in  place  Avith  a  spring-clasp  attachment  passing 
over  the  first  molar,  and  a  partial-clasp  fitting  the  lingual  surface 

Fig.  517. 


of  the  second  ])icusi)i(l,  the  artificial  tooth  and  the  metal  being  shaped 
to  fit  accurately  the  interdental  space. 

Fig.  517  shows  a  similar  removable  bridge  supporting  a  cuspid, 
being  anchored  with  a  spring-cla.sp  attachment  to  a  first  bicuspid. 
The  apparatus  should  be  kept  constantly  in  place,  being  removed 


PERMANENT   RETAINING   DEVICES  437 

only  for  cleansing,  otherwise   the  changing  of  the  position   of  the 
teeth  would  narrow  the  space  and  prevent  its  readjustment. 

In  Fig.  518  is  seen  a  removable  device  for  retaining  teeth  that 
have  been  regulated,  or  that  have  Ix-come  loosened  from  pyorrhcEa 

Fig.  518. 


alveolaris.  When  used  for  the  latter  purpose  it  should  be  worn 
continuously.  Before  making  the  model  on  which  to  form  the 
appliance,  any  of  the  teeth  that  are  elevated  should  be  dressed  with 
a  carborundum  stone  to  correspond  in  length  with  the  adjoining 
ones,  taking  care  not  to  injure  the  pulp.  A  model  of  the  arch  of 
teeth  is  then  to  be  made  and  trimmed  accurately ;  and  when  only 
the  lower  incisors  are  to  be  retained,  form  a  lingual  base-wire,  either 
round  or  half-round,  to  the  curve  of  the  arch,  not  touching  the  gum, 
and  extending  to  a  bicuspid  on  either  side,  to  which  the  ends  are 
anchored  with  spring-clasp  attachments.  Then  make  a  mark  on 
the  model  about  one-sixteenth  of  an  inch  above  the  base- wire  from 
one  side  of  the  arch  to  the  other,  and  remove  the  base-wire.  Fit  a 
thin  piece  of  metal,  about  one-eighth  of  an  inch  wide,  and  long 
enough  to  reach  from  the  anchorage  on  one  side  of  the  arch  to  the 
anchorage  on  the  other,  to  the  lingual  side  of  tlie  teeth  to  be  retained 
just  below  the  line  marked  on  the  incisors.  Use  a  pointed  piece  of 
wood  or  ivory  to  bend  it  into  the  depressions  between  the  teeth.  In 
effect  this  metal  is  similar  to  a  partial-clasp,  and  is  termed  a  con- 
tinuous partial-clasp.  The  base-wire  is  now  to  be  replaced  with  the 
partial-clasp  between  it  and  the  model,  the  upper  edge  projecting  a 
little  above  the  base- wire.  Arrange  a  short  piece  of  small  wire  or  flat 
metal,  with  the  end  curved  in  the  form  of  a  hook,  to  pass  from  the 


438  RETENTION  OF  THE  TEETH 

base-wire  over  the  incisive  edge  at  the  junction  of  two  of  the  teeth, 
and  to  rest  on  the  labial  side,  extending  about  one-sixteenth  of  an 
incli  towards  the  gum,  or  as  far  as  is  necessary  to  retain  them,  fitting 
into  the  natural  depression  formed  by  their  convex  surfaces.  If  the 
appliance  is  to  be  worn  constantly,  as  in  cases  of  pyorrhoea  alveo- 
laris,  the  groove  at  the  junction  and  cutting  edge  of  the  incisors  can 
be  deepened,  if  desired,  sufficiently  to  let  the  curved  portion  of  the 
wire  rest  flush  with  the  edge,  or  the  wire  can  be  flattened  with  a 
carborundum  stone  on  the  outer  or  inner  side  for  the  same  purpose. 

As  many  arms  of  this  kind  as  required  can  be  fitted  to  place  in  the 
same  manner,  one  end  always  extending  onto  the  continuous  partial- 
clasp  to  touch  the  base-wire.  When  the  teeth  are  close  together, 
one  arm  at  the  junction  of  two  teeth  w^ll  hold  that  side  of  each  of 
them.  An  arm  thus  extending  over  the  arch,  on  either  side  of  each 
loose  tooth,  will  prevent  the  teeth  separating  or  rotating. 

The  arms  and  base-wire  are  joined  with  solder  to  the  partial-clasp. 
When  soft  solder  is  used  for  the  purpose,  the  arms  may  be  held  by 
pressmg  down  on  the  curved  portion  with  mouldine  or  a  wad  of 
cotton,  and  the  soldering  done  with  the  soldering  iron.  If  gold  or 
silver  solder  is  to  be  used,  the  model  should  be  made  of  plaster  and 
marble-dust  (or  their  equivalent),  and  the  several  parts  held  in 
position  by  flowing  some  of  the  plaster  mixture  over  the  wires  at 
any  point  that  will  not  interfere  with  the  soldering. 

If  the  teeth  have  become  separated,  as  is  often  the  case  in  pyor- 
rhoea alveolaris,  they  can  be  drawn  together  and  the  arms  arranged 
to  hold  them  in  position  in  tliis  manner.  An  extra  arm  may  be 
added,  or  the  end  of  an  arm  may  be  broadened  by  soldering  a  flat 
piece  of  metal  to  it  in  form  to  rest  on  the  labial  side  of  each  of  the 
adjoining  teeth.  When  preferred,  a  short  arm  can  be  shaped  to 
extend  through  the  space  and  terminate  in  a  slight  hook  to  rest  on 
the  labial  surface. 

This  apjjliance  can  be  utilized  for  retaining  cuspids,  bicuspids,  or 
molars. 

Suspension  Plate  (Fig.  519). — When  a  loose  incisor  that  has 
been  retained  with  an  appliance  like  the  one  last  described  becomes 
entirely  separated  from  its  alveolus,  a  plate  tooth  can  be  made  to 
fill  the  space,  and  fastened  with  solder  to  the  base-wire,  by  making 
a  backing  for  it,  and  united  with  solder  as  in  making  the  appliance. 

Occasionally  patients  prefer  to  have  the  natural  tooth  replaced. 


PERMANENT  RETAINING   DEVICES  439 

This  can  be  done  by  sawing  off  the  root,  leaving  the  crown  the 
proper  length,  and  filling  the  nerve-canal.  A  backing  is  then  fitted 
to  the  crown,  holes  drilled  through  the  backing  into  the  tooth,  and 
long  pins  inserted. 

If  soft  solder  is  used  for  uniting,  the  natural  tooth  will  not  be 
injured  by  the  heat  required,  but  if  gold  or  silver  solder  be  used, 

Fig.    519. 


which  requires  a  higher  temperature,  the  backing  and  pins  should 
be  held  in  place  with  wax  and  the  tooth  removed.  Plaster  and  sand 
are  then  run  about  the  parts  to  hold  them  in  position  while  soldering. 
After  soldering,  the  pins  should  be  serrated  with  a  sharp  instrument, 
and  the  tooth  cemented  to  place  with  oxyphosphate  of  zinc.  When 
a  plate  tooth  is  used  it  should  have  a  backing,  and  be  held  in  place 
for  soldering,  as  in  making  a  metal  plate. 

This  device  I  have  termed  a  "suspension  plate."*  When  the 
gums  are  unhealthy,  it  has  several  advantages  over  the  ordinary 
plate.  It  is  suspended  from  the  teeth,  stimulating  the  tissues  by 
use,  but  causes  no  pressure  on  the  gums,  which  should  be  avoided 
in  cases  of  pyorrhoea  alveolaris,  especially  while  under  treatment. 
It  holds  the  loose  teeth  in  position,  making  them  useful,  at  the  same 
time  supporting  the  artificial  ones. 

When  incisors  have  become  elevated  and  much  too  prominent,  as 
from  pyorrhoea  alveolaris,  generally  after  their  correction  an  appli- 
ance is  required  to  be  worn  constantly  or  at  night  for  their  retention 
(Fig.  520).t  For  drawing  them  into  position  and  retaining  them, 
the  appliance  is  made  by  cementing  to  each  a  collar  with  an  eyelet ; 
or  a  small  wire  eyelet  can  be  cemented  into  the  lingual  side  of 
the  tooth  as  near  the  gum-line  as  practicable.  For  this  a  broad 
shallow  pit  is  first  cut  into  the  concavity  of  the  lingual  surface  of 
the  tooth  at  the  median  line,  as  near  the  gum  as  the  shape 
of  the  tooth  will  permit.  In  each  side  of  the  pit  a  small  hole  is 
drilled,  pointing  outward  laterally  towards  the  sides  of  the  tooth  to 
avoid  the  pulp,  the  holes  being  large  enough  to  admit  the  ends  of 

*  Jackson,  Dental  Cosmos,  1894,  p.  904. 

■f  Jackson,  Trans.  World's  Columbian  Dental  Congress,  1893,  vol.  ii.  p.  680. 


440 


RETENTION   OF  THE  TEETH 


the  eyelet.  This  is  made  of  wire,  with  the  ends  bent  outward  to 
extend  into  the  pits,  then  serrated  and  cemented  to  its  place;  or  in 
making  the  eyelet,  the  ends  can  be  passed  through  a  hole  in  a  small 
round  piece  of  metal,  properly  separated  and  soldered.     A  small- 


FiG.  520. 


sized  lingual  base-wire  is  arranged  at  the  gum  line,  following  the 
curve  of  the  teeth  on  either  side,  and  held  with  spring-clasp  attach- 
ments passing  over  the  bicuspids  or  molars  chosen  for  anchorage. 
Small  Avire  hooks  formed  to  pass  through  the  eyelets  described  are 
soldered  to  the  base-wire.     A  fixed  device  is  applicable. 

A  permanent  retaining  device  is  usually  objectionable  in  appear- 
ance. An  inconspicuous  appliance  that  is  suitable  in  some  cases  for 
retaining  teeth  loosened  by  pyorrhoea  alveolaris  is  sliown  in  Fig.  521. 
It  is  made  by  swaging  a  continuous  partial-clasp  of  thin  metal  to  rest 

Fig.  521. 


on  the  lingual  side  of  the  incisors  extending  near  their  incisive  edge, 
crossing  the  loose  teeth  and  passing  on  to  adjoining  ones  that  are 
sufficiently  firm  to  support  them.  Solder  is  then  flowed  over  the 
partial  clasp  to  stiffen  it. 


PERMANENT   RETAINING  DEVICES  441 

A  small  hole  is  drilled  willi  a  pointed  enamel  drill  between  the 
teeth  that  are  to  be  retained,  the  hole  being  rather  near  the  incisive 
edge  when  the  shape  of  the  teeth  will  permit.  In  some  cases  when 
the  tooth  is  especiallj'  loose,  a  hole  can  be  drilled  through  the  upper 
part  of  it.  The  partial-clasp  is  then  applied,  and  by  means  of  a 
slightly  smaller  drill  the  hole  is  extended  through  the  metal  while 
it  is  held  in  position.  A  small  round  or  oblong  head,  similar  to  that 
of  a  common  pin,  is  formed  on  a  wire,  the  wire  being  of  suitable  size 
to  enter  tlie  hole  drilled  Ijetween  the  teeth.  A  thread  is  cut  on  the 
wire,  and  in  the  hole  in  the  continuous  partial-clasp  into  which  it  is 
to  screw.  A  small  groove  is  made  in  the  head  of  the  screw  to  assist 
in  turning  it  to  place.  In  cutting  the  holes,  those  at  the  extremity  of 
the  continuous  partial-clasp  should  be  cut  first,  and  screws  applied 
to  hold  it  in  place,  then  other  holes  are  drilled  between  the  inter- 
mediate teeth  and  screws  prepared.  After  all  of  the  parts  have  been 
fitted  to  place,  a  rubber  dam  is  applied,  and  a  thin,  slow-setting, 
oxyphosphate  cement  spread  on  the  inner  part  of  the  continuous 
partial-clasp  which  is  put  in  place.  The  screws  should  be  speedily 
adjusted  before  the  cement  hardens. 

If  there  is  a  separation  between  the  teeth,  a  thin  piece  of  metal 
can  be  drilled  for  a  screw,  arranged  to  span  the  space  and  project 
slightly  onto  their  labial  surface. 

When  there  is  to  be  much  occlusal  force,  the  metal  of  the  con- 
tinuous partial-clasp  should  be  swaged  to  extend  over  the  incisive 
edge  of  the  teeth,  and  stiffened  by  flowing  solder  over  it. 

A  similar  device,  more  easily  adjusted,  was  employed  for  Mr.  C. 
The  gum  was  much  receded,  the  incisors  loose  and  irregular.  They 
were  drawn  into  line  and  an  accurate  impression  taken.  A  die  was 
made  and  plate-metal  swaged  forming  a  continuous  partial-clasp 
covering  the  lingual  surface  of  the  teeth  in  front  of  the  tirst  bicuspids, 
extending  from  the  gum  to  the  incisive  edge.  The  metal  was  held  in 
place  and  holes  were  drilled  opposite  the  interdental  spaces,  some  of 
the  holes  being  above  and  others  below  the  line  of  the  cingulum  of 
the  teeth.  Platinum  wire  was  threaded  loosely  through  the  holes 
back  and  forth  around  the  incisors  and  cuspids.  Oxyphosphate  of 
cement  was  forced  downward,  covering  the  front  surface  of  the 
partial-clasp,  which  was  pressed  to  place  and  the  wire  drawn  tightly 
around  each  of  the  teeth  from  side  to  side  and  fastened.  The  device 
has  given  excellent  satisfaction  in  holding  the  teeth  firmly. 


CHAPTER   XXIX 
GENERAL   ORTHOP^DIA    OF   THE   FACE 

The  improvement  of  the  contour  of  the  features  discussed  in 
previous  chapters  include  all  changes  that  we  are  usually  called  upon 
to  make,  but  sometimes  other  orthopaedic  treatment  is  necessary  for 
improving  the  hps,  nose,  eyes,  ears,  and  other  parts.  We  should 
be  thoroughly  conversant  with  the  methods  of  treatment  of  these 
conditions,  but  they  are  best  treated  by  their  respective  specialists, 
and  at  this  time  will  be  only  briefly  described. 

The  Nose. — In  general  orthopgedia  of  the  face,  probably  the  most 
important,  after  operations  on  the  teeth  and  jaws,  is  the  improvement 
of  the  shape  of  the  nose,  both  for  increasing  the  apertures  for 
breathing,  and  for  getting  symmetry  and  facial  harmony.  This  in- 
cludes plastic  operations  on  the  cartilaginous  and  bony  portions,  and 
treatment  with  paraffin. 

As  has  been  pointed  out,  the  shape  of  the  nose  is  often  much 
improved  by  the  regulation  of  the  teeth  and  alveolar  process. 

Fig.  402  illustrates  a  case  with  turned  up,  or  retrousse  nose.  Press- 
ure inward  on  the  tissue  just  below  the  nasal  septum  drew  the  point 
of  the  nose  downward,  improving  its  shape  and  the  general  expres- 
sion. A  plastic  operation  was  recommended  to  bring  about  this 
result,  consisting  in  the  removal  of  some  of  the  redundant  tissue  from 
underneath  the  lip,  the  result  being  the  binding  of  the  parts  at  this 
location  closer  to  the  bone. 

Dr.  Roe*  has  devised  a  subcutaneous  operation  for  correcting 
nasal  deformities,  doing  away  with  the  necessity  of  laying  open  the 
skin,  which  usually  results  in  an  unsightly  blemish.  With  Dr.  Roe's 
approval  I  quote  the  following  from  his  writings : 

"  The  importance  of  correcting  nasal  deformities,  as  well  as  other 
deformities  of  an  unsightly  nature,  is  evident  from  the  conscious 
effect  of  such  deformities  in  influencing  the  habits  and  thoughts  of 
the  person.  On  account  of  this  distinguishing  mark  many  are 
deterred  from  participating  in  the  enjoyment  of  social  life  by  the 

*  John  0.  Roe,  American  Medical  Quarterly,  June,  1899. 
442 


CLASSIFICATION   OF  NASAL   DEFORMITIES  443 

consciousness  of  the  disadvantages  und(^r  wiiicli  they  are  continually 
laboring.  So  universally  recognized  are  the  disadvantages  of  a 
deformed  and  unsiglilly  nose,  that,  even  in  ancient  times,  much 
attention  was  given  lo  Ihe  shajjc  and  appearance  of  this  important 
feature.  It  is  said  that  among  the  ancient  Persians  no  man  who 
had  a  crooked  or  deformed  nose  was  allowed  to  sit  upon  the  throne, 
and  children  of  royal  blood  w'ere  accustomed  to  have  their  noses 
moulded  into  perfect  shaj)e  by  the  eunuchs  who  had  charge  of  the 
royal  oflspring. 

"  Nasal  deformities  are  usually  divided  into  two  main  classes, — (1) 
idiopathic  or  congenital,  and  (2)  traumatic  or  ac(piired.   .  .  .  But, 
from  a  surgical  point  of  view,  nasal  deformities  may  more  ])roperly 
be  divided  into  (1)  the  deformities  which  affect  the  bony  portion 
of  the  nose,  and  (2)  the  deformities  wiiich  affect  the  cartilaginous 
portion.     This  division  can  be  clearly  understood  by  reference  to 
Fig.  522,  which  illustrates  the  anatomical  conformation  of  the  differ- 
ent parts  of  the  nose.     Deformities  of  the  Fiq.  522. 
bony  portion  may  be  subdivided  into  («)       ts      >7 
vertical,  that    is,  those  which    distort  the       \    \ a"^w/>^^3  »/-/^ 
dorsal  profile,  in  which  the  dorsal  line  is       /     T\"T"r1'l!7' 
too  convex,  or  too  concave,  and  (6)  lateral,    '^^j^^M^^^T^j'^'r^rhirra/^t./ag, 
that  is,  those  w'hich,  when  viewed  from  the             Si*^^ 
front,  present  unusual  deviation  from  the  normal  contour,  whereby 
the  bony  portion  may  be  either  spatulated,  or  deflected.     Deformities 
of  the  cartilaginous  portion  may  be  confined  to  the  tip  of  the  nose, 
to  the  shield-cartilages,  or  to   the  wings   of  the  nose.     They  may 
therefore  be  subdivided  into  (a)  those  w'hich  affect  the  tip  of  the  nose, 
whether  excessive  or  defective  in  the  amount  of  tissue,  or  distorted 
from  its  normal  direction  ;  and  [b)  those  wHich  affect  the  wings  of 
the  nose,  which  may  be  either  collapsed  or  abnormally  expanded. 

"  In  correcting  deformities  of  the  nose,  we  have  to  study  the 
symmetrical  relations  of  the  different  portions  of  tlie  nose  to  one 
another  rather  than  its  proportionate  relation  to  the  face.  A  nose 
which  is  originally  proportionate  to  the  face  will,  if  deformed  by  loss 
or  displacement  of  tissue  of  any  portion,  appear  very  unsightly, 
while  the  same  nose,  made  one  or  two  sizes  smaller,  will,  if  its 
different  parts  are  made  perfectly  symmetrical,  have  a  more  or  less 
handsome  appearance.  Therefore,  in  correcting  deformities  of  the 
nose,  it  is  symmetry  and  not  size  that  is  to  be  considered. 


444  GENERAL  ORTHOPiEDIA   OF  THE  FACE 

"In  this  way  it  will  readily  be  seen  that  the  causes  and  conditions 
of  the  different  deformities  of  the  nose  are  so  various  that  the  opera- 
tions required  for  the  correction  of  these  deformities  must  be  equally 
varied,  nor  will  any  two  cases  be  found  exactly  alike,  and  requiring 
the  same  operation. 

"  There  are,  however,  general  underlying  principles  governing  the 
different  operations  which  must  be  observed  in  order  to  secure  the 
desired  result.  Thus,  in  the  convex  vertical  deformity  of  the  bony 
portion  of  the  nose  and  excessive  development  of  the  tissues  of  the 
tip  of  the  nose,  the  excessive  or  redundant  tissues  must  be  removed  ; 
whereas,  in  the  concave  vertical  deformity  of  the  bony  portion  of 
the  nose  or  of  defective  development  of  the  tip  of  the  nose,  the  low 
portions  must  be  filled  in.  Usually  this  can  be  done  with  tissue 
taken  from  the  elevated  portions,  so  as  to  make  the  nose  sym- 
metrical, or  w'hen  this  cannot  be  accomplished  by  the  transfer  of 
tissue  from  the  elevated  to  the  low  portions,  the  latter  can  be  filled 
in  by  tissue  taken  from  some  other  portion  of  the  nose,  wdiere  it  can 
be  spared,  and  the  elevated  portions  lowered  so  as  to  make  the  nose 
symmetrical. 

"  In  many  forms  of  distortion  of  the  nose,  especially  those  result- 
ing from  injury,  there  is  almost  invariably  a  displacement  rather 
than  a  destruction  of  tissues,  which  require  only  to  be  replaced  in 
their  original  position.  It  is  important,  how^ever,  that  all  of  these 
operations  be  performed  subcutaneously,  in  order  to  avoid  the 
wounding  of  the  skin  and  the  consequent  disfigurement.  In  some 
instances  fracture  of  the  nasal  bones  and  of  the  septum,  too,  may 
also  be   necessary  in   order  to  restore  the  parts  to  a 

r  normal  condition. 

"  Fig.  523.     The  convex  vertical  deformity  consists 
of  an  undue  projection  of  the  anterior  process  of  the 
nasal  bones,  giving  to  the  nose  an  angular  appearance. 
"This  deformity  is  the   one   most  often  found  un- 

-    ^  complicated,  and  the  operation  for  its  correction  is  in 

the  main  perfonued  as  follows : 

"  The  skin  is  first  raised  from  the  projecting  portion  by  incising 
the  wall  of  the  nose  from  the  inside  of  the  nostrils  through  to  the 
under  side  of  the  skin,  care  being  exercised  not  to  wound  the  skin. 
The  opening  is  then  enlarged  sufficiently  to  admit  the  instrument 
required,   which    may   consist  of  bone-scissors,   rongier  forceps,   a 


TREATMENT  OF  NASAL  DEFORMITIES 


446 


slender  saw,  or  such  other  instruiiieut  as  may  be  necessary  accord- 
ing to  the  conditions  present. 

"In  removing  the  projecting  portions,  great  care  must  be  exer- 
cised not  to  remove  too  much  of  tlie  rechmdant  tissue,  h'st  a  depres- 
sion be  left  in  tiio  toj)  of  tlic  nose  whicii  may  l)e  more  unsightly  tiian 
the  original  deformity.  This  mistake  more  readily  happens  in  those 
cases  in  which  the  upper  i)ortion  of  the  nasal  passage  extends  all  the 
way  up  into  this  projecting  portion.  In  these  cases  the  na.sal  passage 
is  very  easily  opened  on  removing  the  projecting  angular  portion. 

"  Fig.  524.  The  concave  deformity,  sometimes  termed  saddle- 
back nose,  consists  in  a  lowering  or  flattening  of  the  bridge  of  the 
nose,  and  may  be  either  idiopathic  or  traumatic. 

"  The  operations  for  tlie  correction  of  this  deformity  are  entirely 
different  from  the  last,  and  consist  in   filling  in  the  depressed  por- 

FiG.  524. 

Fig.  525.  Fig.  526. 


tions  with  flaps  of  tissue  taken  from  the  unduly  ])rominent  portion, 
subcutaneously,  thereby  lowering  that  portion  at  the  same  time. 

"  Fig.  525.  The  spatulated  deformity  may  consist  in  a  flattening 
of  the  dorsum  and  bulging  outward  of  the  nasal  bones,  or  in  a 
deflection  of  this  portion  of  the  nose  to  one  or  the  other  side. 

'*  The  correction  of  this  deformity  usually  consists  in  sawing  off 
portions  of  the  bulging  nasal  bones,  and  placing  these  bone  flaps, 
together  with  the  attached  soft  tissues,  in  the  median  line  in  such  a 
position  as  will  fdl  in  the  depressed  portion.  This  deformity  is 
almost  always  associated  with  an  enlarged  condition  of  the  end  of 
the  nose,  wdiich  requires  a  corresponding  amount  of  reduction  in 
order  to  make  the  nose  symmetrical. 

•Fig.  526.  Deflections  of  the  bony  portion  of  the  nose  may  be 
due  to  an  unequal  growth  of  the  two  sides  of  the  nose,  or  to  injuries 
causing  dislocations  of  the  nasal  bones,  wdiich,  at  the  time  of  the 
injury,  were  not  properly  reduced. 


446 


GENERAL  ORTHOP.EDIA  OF  THE  FACE 


"This  deformity  may  be  corrected  by  two  different  methods. 
First,  by  refracturing  the  bones  and  holding  them  in  the  desired 
position  until  firmly  fixed.  Second,  by  a  subcutaneous  osteoplastic 
operation,  which  consists  in  elevating  the  skin  from  the  dorsum, 
sawing  off  with  a  slender  saw  the  projecting  portion,  and  placing  it 
in  the  depression  on  the  other  side  of  the  nose. 

"Fig.  527.  The  abnormal  enlargement  of  the  tip  or  anterior  por- 
tion of  the  end  of  the  nose  may  be  due  to  an  excessive  development 
of  the  tissues  of  this  region,  consisting  of  a  redundant  amount  of  carti- 
laginous tissue,  or  to  an  excessive  amount  of  fatty  tissue,  or  to  both 
combined.  This  enlarged  condition  of  the  end  of  the  nose  is  what  is 
commonly  known  by  the  term  '  snub-'  or '  pug-nose,'  and  is  frequently 
associated  with  the  concave  vertical  deformity  of  the  bony  portion. 


Fig.  527. 


Fig.  528. 


"  The  so-called  pug-  or  snub-nose  is  corrected  by  removing  the 
redundant  tissue  from  the  end  of  the  nose  subcutaneously.  The 
operation  is  performed  from  the  interior  of  the  nostril.  .  .  .  The 
sensitiveness  of  the  part  is  first  deadened  with  cocaine,  then  the 
tissues  are  brightly  illumined. 

"Fig.  528.  When  the  tissue  of  the  lower  portion  of  the  nose  is 
deficient  in  amount,  there  is  a  corresponding  flattening  of  the  end. 
termed  'frog-nose.'  In  extreme  cases  the  end  of  the  nose  is  com- 
pletely flattened  upon  the  face. 

"  This  deformity  is  corrected  by  filling  in  the  deficiency  with  tissue 
taken  from  adjacent  parts,  by  plastic  operations,  performed  subcu- 
taneously, varied  according  to  the  requirements  of  the  case. 

"Fig.  529.  Deviation  of  the  cartilaginous  portion  of  the  nose 
may  be  due  to  the  unequal  vertical  growth  of  the  ahe,  forcing  the 
nose  over  to  one  side ;  or  there  may  be  unequal  development  in  the 
thickness  of  the  two  wings,  distorting  the  nose,  and  giving  it  the 
appearance  of  being  deflected. 


TREATMENT  OF  NASAL  DEFORMITIES  447 

"The  correction  of  this  deformity  consists  in  loosening  the  nose 
by  subcutaneous  incisions  so  that  it  can  be  placed  in  its  normal 
position  in  the  median  line  of  the  face,  and  held  there  until  firmly 
fixed. 

"  Fig.  530.  In  the  collapsed  condition  there  is  an  undue  flatten- 
ing of  the  sides  of  the  nose,  interfering  seriously  with  the  nasal 
respiration.  This  may  be  due  to  defective  or  distorted  development 
of  the  al?e,  or  to  paralysis  of  the  dilatores  naris  muscles,  cicatricial 
contraction,  etc. 

"  The  operation  in  these  cases  consists  in  incising  the  lower  shield- 
cartilage,  and  in  some  cases  the  upper  shield-cartilage  also,  suffi- 

FiG.  530.  Fig.  531.  Fig.  532. 


ciently  to  overcome  their  elasticity,  and  then  to  hold  them  in  the 
desired  position  until  fixation  of  the  tissues  has  taken  place. 

"  Fig.  531.  Expansion  or  spreading  of  the  wings  of  the  nose  is 
usually  of  congenital  origin,  and  consists  of  a  marked  distention  or 
bulging  outward  of  the  lower  shield-cartilages,  giving  the  end  of  the 
nose  a  very  broad,  prominent,  and  inordinately  flat  appearance. 
On  examination,  however,  it  will  be  found  that  there  is  but  little 
thickening  of  the  tissues,  the  concavity  of  the  interior  being  propor- 
tionate to  the  extreme  bulging. 

"  The  operation  for  the  correction  of  this  condition  consists  in 
overcoming  the  elasticity  of  the  wings  by  incisions  through  the 
shield-cartilages  simultaneously  with  a  slender  knife  in  several 
places,  and  then  holding  them  in  place  by  an  external  form  until 
they  are  firmly  fixed  in  the  desired  position.  In  some  instances 
the  cartilage  is  so  redundant  that  a  portion  of  it  must  be  excised." 

In  order  to  maintain  symmetry,  after  any  of  these  operations  it  is 
important  that  the  tissues  be  held  in  the  desired  form  until  healing 
has  taken  place.  Adhesive  plaster  and  a  metallic  form  are  usually 
applied  to  the  surface  of  the  nose,  as  illustrated  in  Fig.  532.  An 
internal  splint  is  sometimes  employed,  as  after  an  operation  on  the 


448  GENERAL  ORTHOP^DIA  OF  THE  FACE 

septum  and  nasal  bones.  A  dressing  is  applied  to  the  interior  of 
each  nostril  in  the  form  of  a  splint  wound  with  cotton,  so  as  to 
maintain  the  bone  in  an  elevated  position,  and  at  the  same  time  to 
hold  the  fractured  septum  in  a  vertical  position  until  healed. 

In  Dr.  Roe's  writings  may  be  found  many  photo-engravings  illus- 
trating cases  before  and  after  correction. 

Fig.  533  shows  the  case  of  a  young  lady  with  angular  deformity 
of  the  nose.*  The  improved  condition  after  operation  is  shown  in 
Fig.  534.  Fig.  535  illustrates  a  young  man  with  a  "pug-nose."t 
Fig.  536  shows  the  improved  condition. 

Paraffin  Treatment  for  Deformities. — Some  malformations  of 
the  nose  and  other  parts  are  corrected  by  the  subcutaneous  injection 
of  paraffin.  It  must  be  admitted  that  the  matter  of  paraffin  treat- 
ment is  yet  in  a  tentative  state.  In  1900  Gersuny,  of  Vienna,!  first 
described  tlie  operation  in  the  treatment  of  other  portions  of  the 
body,  stating  that  he  had  been  conversant  with  the  method  a  number 
of  years.  Quintan  says  that  solidifying  oils  were  introduced  sub- 
cutaneously  for  the  relief  of  pain  by  Dr.  Corning,  of  New  York,  in 
the  eighties.  Smith, §  Quinlan,||  and  others  have  described  methods 
of  building  up  and  correcting  deformities,  as  filling  congenital  gaps, 
overcoming  changes  resulting  from  cicatrices  following  loss  of  tissue, 
congenital,  traumatic,  and  specific  affections  of  the  external  nose, 
hollow  cheeks,  and  the  various  depressions  attended  by  facial 
deformity. 

Heath,  of  St.  Paul,  describes  in  "American  Medicine"  its  use  in 
the  treatment  of  a  case  where  the  entire  cartilaginous  septum  was 
destroyed, 

Haskins  employs  paraffin  prosthesis  to  prevent  deformity  after 
mastoid  operations. 

Quinlan  describes  the  technique  and  shows  an  instrument  for  the 
injection  of  paraffin.  He  points  out  tiie  (lifTicnlty  of  introducing  it 
into  the  desired  part,  and  the  danger  from  embolism  of  the  lungs 
when  the  paraffin  is  injected  in  a  liquid  state.  This  they  claim  to 
obviate  by  injecting  it  in  a  solid  or  semisolid  form. 

*  Roe,  Medical  Record,  July,  1891. 

t  II. id.,  Jiiiie,  1887. 

X  Moskowitz  in  Wieru-r  Kliiiiscli.;  \Voch.,  No.  25,  1901. 

§  Smith,  Nfw  York  Medical  Journal,  May,  1902. 

II  Quinlan,  Laryngoscope,  August,  1902. 


Vui.  :>;«. 


Fk;.  r,;;4. 


Fig.  535. 


Fii;.  53P.. 


TREATMENT  OF  HOLLOW  CHEEKS,  EYE,  EAR,  CLEFT-PALATE  449 

Hollow  Cheeks. — Wlicu  the  cheeks  are  deficient  in  fulness,  the 
contour  can  generally  be  improved  by  the  insertion  of  a  plumper,  at- 
tached to  the  teeth  on  one  or  both  sides  of  either  the  upper  or  lower 
arch.  If  the  natural  teeth  are  absent,  plumpers  can  be  made  by  form- 
ing an  extension  of  rubber  in  connection  with  a  full  or  partial-plate, 
but  when  the  natural  teeth  are  in  situ,  a  spring-clasp  can  be  fitted  to 
one  or  more  of  them  on  the  lingual  surface,  with  the  ends  extending 
to  the  buccal  side  to  enter  a  pad  of  vulcanite 
shaped  in  any  form  desired.  Both  the  upper  and 
lower  surfaces  of  the  pad  may  be  made  convex, 
or  be  concave  on  the  occlusal  side.  Fig.  537  illus- 
trates a  device  that  was  used  in  the  upper  arch  for 
Dr.  C.  One  cheek  was  considerably  depressed, 
and  the  application  of  the  plumper  caused  the 
cheeks  to  harmonize. 

Eye, — Plastic  operations  upon  the  eyelids  for 
improving  the  facial  expression  are  principally  em- 
ployed for  Mongolians,  Canthoplasty  is  an  opera- 
tion on  the  canthus  of  the  eye,  recommended  by 
Ammon,  when  the  eyelids  are  not  sufficiently  cleft. 

A  fold  of  skin  is  sometimes  formed  over  the  inner  angle  of  the 
eye  termed  epicanthus.  This  is  corrected  by  the  removal  of  a 
rhomboidal  piece  of  skin,  about  an  inch  in  length  and  nearly  two- 
thirds  of  an  inch  in  width  at  its  greatest  part.  It  is  excised  from  the 
side  of  the  nose.  The  skin  at  both  sides  of  the  wound  is  carefully 
raised,  approximated,  and  held  together  by  silk  sutures.  Immediate 
union  is  encouraged  by  the  use  of  plaster  strips,* 

The  correction  of  squint,  or  strabismus,  and  applying  artificial 
eyes  after  enucleation  should  be  mentioned. 

Ear, — Deformity  of  the  auricle  is  sometimes  improved  by  surgical 
treatment.  When  the  ear  is  too  prominent,  some  of  the  cartilagi- 
nous concha  can  be  removed,  for  depressing  the  helix  and  anti- 
helix.     In  young  children  the  application  of  bandages  is  effective, f 

Kingsley  describes  in  detail  the  making  of  artificial  lip,  nose,  and 
ear.t 


*  Knapp,  Archives  of  Ophthalmology,  vol.  iii.  p.  53. 
t  Bench,  Diseases  of  the  Ear,  1903,  p.  173. 
J  Kingley's  Oral  Deformities. 
29 


450         GENERAL  ORTHOP.EDIA  OF  THE  FACE 

Cleft  Palate  and  Harelip. — Staphylorrhaphy,  an  operation  for 
uniting  a  cleft  palate,  was  first  performed  by  a  dentist,  Le  Mounier, 
in  1764.  Such  a  small  percentage  of  cases  have  proved  successful, 
that  some  surgeons  oppose  the  operation,  claiming  it  to  be  imprac- 
ticable ;  but  it  is  now  encouraged  and  performed  successfully,  notably 
by  Brophy.*  When  cleft  palate  is  accompanied  with  harelip,  the 
fissure  of  the  lip  and  the  nasal  and  maxillary  bones  are  united. 
Kingsley  f  treats  of  these  defects  surgically,  and  mechanically  by  the 
use  of  obturators  and  artificial  vela. 


*  Brophy,  Transactions  of  the  World's  Columbian  Dental  Congress,  vol.  ii. 
p.  532  :  Dental  Cosmos,  1901,  p.  867. 
J  Kingsley' s  Oral  Deformities. 


APPENDIX 

The  following  page  plates  illustrate  appliances  that  have  been 
used  in  practice  for  the  regulation  and  retention  of  the  teeth. 
There  are  many  variations  in  the  anchorage,  location,  and  com- 
bmation  of  the  base-wires,  and  arrangement  of  the  springs.  They 
are  brought  together,  classified,  and  presented,  that  their  examina- 
tion may  assist  the  operator  or  the  student  by  suggesting  methods 
of  procedure.  The  descriptions  are  necessarily  brief.  The  anchor- 
age of  some  of  the  appliances  would  be  improved  by  additional 
partial-clasps. 


451 


LIST  OF  PLATES 

PAGE  PLATES  OF  APPARATUS  USED  IN  PRACTICE 

PLATE  PAGE 

I.   Arch,  Lower,  Expansion  of,   Laterally 456 

II.   Arch,  Lower,  Expansion  of,  Anteriorly 457 

III.  Arch,  Upper,  Expansion  of.   Laterally 458 

IV.  Arch,  Upper,  Expansion  of,  Anteriorly 459 

V.   Arch,  Expansion  of,  Unilaterally 460 

VI.   Arch,  Contraction  of 461 

VII.   Incisors,  Lower,  to  move  Outward 462 

VIII.  Incisors,  Lower,  to  move  Outward 463 

IX.   Incisors,  Upper,  to  move  Outward 464 

X.   Incisors,  Upper,  to  move  Outward 465 

XI.   Incisors,  Upper,  to  move  Outward 466 

XII.   Incisors,  Upper,  to  move  Outward 467 

XIII.  Incisors,  Upper,  to  move  Outward 468 

Incisors,  Upper,  to  move  Outward  Bodily 468 

XIV.  Incisors,  Lower,  to  move  Inward 469 

XV.   Incisors,  Upper,  to  move  Inward 470 

XVI.   Incisors,  Upper,  to  move  Inward 471 

XVII.   Incisors,  Upper,  to  move  Inward 472 

XVIII.   Incisors,  LTpper,  to  move  Inward 473 

XIX.   Incisors,  Rotation  of 474 

XX.   Incisors,  Rotation  of 475 

XXI.   Incisors,  Rotation  of 476 

XXII.   Incisors,  to  move  Laterally 477 

XXIII.  Cuspids,  to  move  Outward 478 

XXIV.  Cuspids,  Lower,  to  move  Inward 479 

XXV.   Cuspids,  to  move  Inward 480 

XXVI.   Cuspids,  to  move  Inward 481 

XXVII.   Cuspids,  to  move  Inward  and  Backward 482 

XXVIII.   Cuspids,  to  move  Inward  and  Backward 483 

XXIX.   Cuspids,  to  move  Backward  in  the  line  of  the  Arch 484 

XXX.   Bicuspids,  to  move  Outward 485 

XXXI.   Bicuspids,  to  move  Outward 486 

Bicuspids,  to  move  Inward 486 

XXXII.   Bicuspids,  to  move  Backward 487 

Bicuspids,  to  move  Forward 487 

Bicuspids,  to  relieve  Impaction  of 487 

453 


454  LIST  OF  PLATES 

PLATE  PAGE 

XXXIII.  Molars,  to  move  Backward 488 

Molars,  to  move  Forward 488 

Molars,  to  move  Outward 488 

Molars,  to  move  Inward 488 

Equalizing  the  Jaws ■  .    .     .    .  488 

Retaining 488 

XXXIV.  Retaining 489 

XXXV.   Retaining 490 

XXXVI.   Retaining 491 

XXXVII.   Arch,  Expansion  of 492 

XXXVIII.   Incisors,  to  move  Outward 493 

XXXIX.   Incisors,  to  move  Inward 494 

XL.   Incisors,  to  move  Inward 495 

XLI.   Incisors,  to  Depress 496 

XLII.   Cuspids,  to  move  Outward 497 

Cuspids,  to  move  Inward 497 

XLIII.    Bicuspids,  to  move  Outward 498 

Bicuspids,  to  move  Inward 498 

Bicuspids,  to  move  Backward 498 

Bicuspids,  to  move  Forward 498 

XLIV.    Retaining 499 


PLATE    I 
Arch,  Lower,  Expansion  of,  Laterally 

A.  An  appliance  for  the  lateral  expansion  of  the  lower  arch,  anchored 
by  spring-clasp  attachments  over  the  first  bicuspids  and  first  molars,  with  partial- 
clasps  fitting  other  teeth.  A  lingual  spring  base-wire  enters  the  centre  of  the 
anchorage  portion,  permitting  a  change  of  angle  for  expanding  either  the  distal  or 
front  part  of  the  arch. 

B.  A  device  for  lower  lateral  expansion.  It  is  retained  by  spring-clasp 
attachments  to  the  second  bicuspids  and  partial-clasps  fitting  the  adjoining  teeth. 
Two  springs  are  attached  in  the  anterior  portion  of  the  anchorage  for  moving 
incisors  outward. 

C.  An  apparatus  for  lower  lateral  expansion,  with  a  spring  base-wire  bent 
into  loops  located  back  of  the  incisors. 

D.  An  appliance  with  a  spring  base-wire  shaped  into  loops,  anchored  to  the 
permanent  molars.     A  spring  is  attached  for  moving  the  incisors  outward. 

E.  A  device  for  the  lateral  expansion  of  the  arch,  with  a  finger-spring 
attached  for  moving  the  incisors  outward. 

F.  An  appliance  witli  cast-metal  sides  connected  with  a  lingual  spring  base- 
wire  having  a  U-shaped  loop  arranged  at  the  median  line  and  anchored  by  wire- 
clasps.  Action  is  caused  by  opening  the  loop  from  time  to  time.  To  each 
anchorage  portion  a  spring  is  attached  extending  in  a  curve  to  the  opposite  side 
of  the  arch  for  moving  the  incisors  outward. 


456 


Plate  I 


Plate  II 


PLATE    II 
Arch,  Lower,  Expansion  of,  Anteriorly 

A.  An  appliance  with  a  lingual  spring  base-wire  resting  low  in  the  arch,  the 
ends  entering  the  centre  of  the  anchorage  portion  from  below  upward.  A  finger- 
spring  is  attached  in  the  anchorage  extending  forward  to  expand  the  anterior 
part  of  the  arch.  The  free  end  of  the  spring  was  retained  in  position  by  passing 
under  a  lug  on  a  collar  cemented  to  one  of  the  incisors.  Springs  for  this  purpose 
should  always  be  retained,  using  collars  on  one  or  more  teeth  as  required. 

B.  A  device  with  a  lingual  base-wire.  A  long  and  a  short  finger-spring 
extends  forward  from  the  anchorage  for  expanding  the  arch. 

C.  A  lingual  base-wire  is  anchored  by  spring-clasp  attachments  to  a  first 
permanent  molar  and  a  second  deciduous  molar.  Two  springs  extend  forward 
from  the  anchorage  in  a  curve,  terminating  on  the  opposite  side  of  the  arch  for 
moving  incisors  outward. 

D.  An  apparatus  anchored  by  spring-clasp  attachments  over  the  first  perma- 
nent molars,  with  two  springs  extending  forward  for  anterior  expansion. 

E.  A  device  anchored  to  the  second  deciduous  molars,  with  springs  extend- 
ing forward  to  force  the  incisors  outward. 

F.  An  appliance  with  a  lingual  base-wire  anchored  by  spring-clasp  attach- 
ments to  the  second  bicuspids.  The  anterior  part  of  the  base-wire  was  arranged 
to  leave  a  little  space  between  it  and  the  gum.  A  semicircular  spring  with  two 
U-shaped  loops  was  formed  to  the  lingual  side  of  the  incisors,  passing  under  lugs 
on  collars,  the  loops  resting  between  the  base- wire  and  the  gum,  and  the  ends 
soldered  by  the  ends  of  the  base-wire  in  the  anchorage  portion.  Action  was 
effected  by  opening  the  loops  from  time  to  time. 


457 


PLATE    III 
Arch,  Upper,  Expansion  of,  Laterally 

A.  An  appliance  with  a  palatine  spring  base-wire  crossing  the  distal  part 
of  the  arch.  The  ends  of  the  wire  were  bent  forward  forming  arms  and  shaped 
to  enter  the  anchorage.  The  arch  was  expanded  by  bending  outward  the  arms  as 
required. 

B.  A  device  with  a  palatine  base-wire  located  in  the  distal  part  of  the  arch. 
Force  is  got  by  bending  outward  the  anterior  portion,  or  arms. 

C.  An  appliance  with  a  palatine  base-wise  arranged  to  cross  the  distal  part 
of  the  arch  where  the  arch  is  broad  enough,  the  ends  bent  forward  and  soldered 
in  the  anchorage.  Action  is  exerted,  by  bending  outward  the  front  parts  of  the 
anchorage. 

D.  A  palatine  spring  base-wire  with  a  U-shaped  loop  for  the  lateral  expan- 
sion of  the  arch.  The  loop  points  backward  and  the  ends  of  the  base-wire  are 
bent  backward  to  enter  the  anchorages.  Force  is  caused  by  opening  the  loop  a 
little  at  a  time. 

E.  A  looped  spring  base-wire.  The  loop  at  the  median  line  is  arranged  to 
point  forward.  The  ends  are  bent  forward  in  a  gentle  curve  to  be  soldered  in 
the  anchorage.  The  ends  of  a  looped  spring  are  attached  in  the  anterior  part  of 
the  anchorage  for  moving  incisors  outward. 

F.  A  jack-screw  arranged  for  the  lateral  expansion  of  the  arch,  anchored  by 
partial-clasps  and  spring-clasp  attachments. 


458 


Plate  III 


D 


Plate  IV 


PLATE    IV 
Arch,  Upper,  Expansion  of.  Anteriorly 

A.  An  appliance  with  a  palatine  base-wire  anchored  by  spring-clasp  attach- 
ments over  the  second  bicuspids.  A  spring  extends  forward  from  the  anchorage 
on  either  side  of  the  arch  to  rest  on  the  lingual  side  of  the  incisors  for  moving 
them  outward.     The  springs  are  retained  by  lugs  on  collars  cemented  to  the  teeth. 

B.  A  palatine  base-wire  arranged  to  cross  the  distal  part  of  the  arch  with 
the  ends  bent  forward.  A  spring  is  attached  to  each  anterior  anchorage  portion 
and  formed  to  follow  the  lingual  curve  of  the  arch  to  the  opposite  side  where  it  is 
retained  by  a  lug  on  a  collar.  Action  is  caused  by  bending  the  springs  forward. 
The  anterior  part  of  the  arch  is  expanded  laterally  by  bending  outward  the 
anchorage  portions. 

C.  A  device  with  a  palatine  base-wire  and  a  semicircular  spring  with 
U-shaped  loops.  The  loops  are  opened  slightly  at  a  time  for  getting  force, 
expanding  the  anterior  part  of  the  arch.  An  artificial  tooth  is  supported  by  the 
anchorage. 

D.  An  apparatus  with  a  palatine  base-wire  and  semicircular  spring  with 
loops.  To  the  anterior  part  of  the  spring  is  attached  a  curved  spring  which 
was  utilized  for  evening  the  circle  of  the  incisors. 

E.  An  appliance  similar  to  the  one  last  described,  with  a  spring  attached  to 
the  semicircular  spring  for  moving  outward  incisors  and  cuspids. 

F.  An  appliance  for  expanding  the  anterior  part  of  the  arch  similar  to  the 
ones  previously  described.  The  palatine  base-wire  is  arranged  to  cross  the 
distal  part  of  the  arch,  and  the  anterior  portion  of  the  anchorage  is  bent  out- 
ward for  expanding  the  arch  laterally. 


459 


PLATE    V 
Arch,  Expansion  of.  Unilaterally 

A.  An  appliance  having  a  lingual  spring  base-wire  with  a  loop  arranged  on 
one  side  for  expanding  the  lower  arch  unilaterally. 

B.  A  palatine  spring  base-wire  with  one  end  curved  backward  to  be  attached 
in  the  anchorage,  and  the  other  end  curved  forward  for  moving  outward 
bicuspids,  the  end  being  retained  by  spring-clasp  attachments. 

C.  A  palatine  spring  base-wire  with  a  U-shaped  loop  at  the  median  line. 

D.  A  lingual  spring  base-wire  strongly  anchored  on  one  side  with  spring- 
clasp  attachments  and  a  metallic  plate  shaped  to  cover  a  portion  of  the  palatine 
arch.  The  other  end  was  anchored  by  a  spring-clasp  attachment  over  a  bicuspid 
to  be  moved. 

E.  An  expanding  device  with  a  palatine  spring  base-wire  in  the  form 
of  a  loop.  Plate  metal  was  shaped  to  cover  a  portion  of  the  palatine  arch  to 
strengthen  the  anchorage  on  one  side  for  moving  outward  a  bicuspid  and  a  molar 
on  the  opposite  side. 

F.  A  palatine  base-wire  in  the  form  of  a  loop,  strongly  anchored  to  the 
teeth  by  spring-clasp  attachments  and  plate  metal  covering  a  portion  of  the  arch, 
used  for  moving  outward  a  molar  and  two  bicuspids  on  the  opposite  side  of  the 
arch. 


460 


Plate  V 


E 


Plate  VI 


PLATE    VI 
Arch,  Contraction  of 

A.  A  lingual  base-wire  device  with  a  continuous  spring-clasp  arranged  for 
nnoving  inward  a  cuspid  and  the  bicuspids  on  one  side  of  the  arch.  A  promi- 
nent cuspid  on  the  opposite  side  was  moved  inward  by  a  spring  bent  twice 
at  right  angles  with  the  parallel  arms  extending  over  the  arch  either  side  of  the 
cuspid  and  bent  towards  each  other  to  rest  on  the  labial  surface  near  the  gum. 
The  teeth  were  moved  inward  by  bending  the  outer  parts  of  the  springs  nearer  to 
the  base-wire. 

B.  A  lingual  base-wire  with  a  semicircular  spring  and  U-shaped  loops, 
for  moving  lower  incisors  inward. 

C.  A  device  for  contracting  the  anterior  part  of  the  lower  arch.  Two  finger 
springs  are  arranged  to  extend  from  a  lingual  base-wire  to  the  buccal  side,  then 
forward  in  a  curve  to  the  opposite  side  of  the  arch. 

D.  An  appliance  with  a  palatine  base-wire  and  semicircular  spring  with 
loops  for  the  contraction  of  the  upper  arch. 

E.  A  lingual  base-wire  with  looped  spring.  To  the  anterior  part  of  the 
base-wire  are  soldered  pieces  of  plate-metal  for  assisting  the  anchorage  and  even- 
ing the  teeth  as  they  were  moved  inward. 

F.  An  apparatus  with  a  lingual  spring  base-wire,  continuous  spring-clasps 
and  a  semicircular  spring  with  U-shaped  loops  for  the  general  contraction  of  the 
arch.  The  front  teeth  are  moved  inward  by  closing  the  loops  of  the  spring 
a  little  at  a  time,  and  the  arch  contracted  laterally  by  bending  together  from  time 
to  time  the  sides  of  the  base-wire. 


4G1 


PLATE    VII 

Incisors,  Lower,  to  move   Outward 

A.  A  lingual  base-wire  device.  A  curved  finger-spring  is  attached  in 
the  anchorage  on  one  side.  The  free  end  of  the  spring  is  arranged  to  pass  under 
a  lug  on  a  collar  cemented  to  one  of  the  incisors  to  be  moved. 

B.  A  lingual  base-wire  and  finger-spring,  anchored  by  spring-clasp  attach- 
ments to  the  second  bicuspids. 

C.  A  lingual  base-wire  and  finger-spring  arranged  for  moving  outward 
the  lower  incisors  and  a  cuspid.  A  second  spring  is  attached  for  moving  inward 
a  bicuspid. 

D.  A  lingual  base-wire  with  the  arms  projecting  backward  and  upward 
to  enter  the  anchorage  portions.  From  the  front  of  the  anchorage  on  the  right 
side  a  spring  extends  forward  to  move  outward  a  deciduous  cuspid  and  a 
biscupid.  A  spring  is  attached  in  the  anchorage  on  the  left  side  for  moving  out- 
ward instanding  incisors.  The  arch  is  expanded  laterally  by  bending  outward 
the  arms  of  the  base-wire. 

E.  An  appliance  with  a  lingual  base-wire,  a  finger-spring  for  moving 
outward  the  incisors,  and  two  short  springs  for  moving  outward  the  cuspids. 

F.  A  lingual  base-wire,  a  curved  spring  for  moving  outward  the  incisors, 
and  two  springs  extending  forward  for  moving  outward  the  cuspids  and  bicuspids. 


462 


Plate  VII 


Plate  VIII 


D 


PLATE    VIII 
Incisors,  Lower,  to  move   Outward 

A.  An  appliance  for  moving  a  crowded  incisor  outward.  It  has  a  lingual 
base-wire  and  a  finger-spring.  To  the  finger-spring  i.s  attached  a  secondary 
spring  with  arms  passing  over  the  arch  either  side  of  the  tooth  to  be  moved  ; 
the  arms  are  separated  to  broaden  the  space.  The  ends  of  the  spring  are  bent 
outward  and  backward  to  press  on  the  adjoining  teeth  to  assist  the  action  of  the 
finger-spring. 

B.  A  lingual  base-wire  with  two  finger-springs  attached,  one  for  moving 
outward  the  incisors,  and  the  other  for  moving  outward  a  cuspid  and  bicuspid. 

C.  A  device  with  a  lingual  base-wire  and  two  finger-springs  extending 
forward  in  a  curve,  one  from  either  side  of  the  arch.  The  ends  of  the  springs  in 
this  and  in  similar  devices  are  retained  by  passing  under  a  lug  on  a  collar 
cemented  to  one  or  more  of  the  teeth. 

D.  A  lingual  spring  base-wire  with  the  ends  attached  in  the  centre  of 
the  anchorage  portion.  Two  finger-springs  extend  to  the  front  of  the  arch  for 
moving  the  incisors  outward.  A  curved  spring  is  arranged  to  move  outward 
a  cuspid,  at  the  same  time  the  arch  is  expanded  laterally  by  the  action  of  the 
spring  base-wire. 

E.  An  appliance  with  a  semicircular  spring  and  U-shaped  loops.  The 
loops  are  arranged  to  rest  between  the  base-wire  and  the  gum.  Action  is  caused 
by  opening  the  loops. 

F.  A  lingual  base-wire  and  semicircular  spring  with  U-shaped  loops  for 
moving  lower  incisors  outward. 


463 


PLATE    IX 
Incisors,  Upper,  to  move   Outward 

A.  An  appliance  with  a  palatine  base-wire.  A  spring  extends  forward  from 
the  anchorage  on  one  side  to  pass  under  a  lug  on  a  collar  cemented  to  one  of  the 
incisors  for  moving  it  outward. 

B.  A  broad  palatine  base-wire  with  a  curved  finger-spring  extending 
forward  from  the  anchorage  on  one  side  to  be  retained  by  a  lug  on  a  collar. 

C.  An  appliance  with  a  long  curved  finger-spring  extending  from  the 
anchorage  over  the  arch  at  the  junction  of  two  of  the  teeth  to  the  buccal  side, 
then  forward  to  pass  under  a  hook  on  the  labial  side  of  a  collar  cemented  to  the 
tooth  to  be  moved.  This  appliance  was  used  for  moving  outward  an  incisor 
in  case  of  close  bite. 

D.  A  device  with  a  j^alatine  base-wire  and  a  long  finger-spring  extending 
forward  to  rest  on  the  lingual  side  of  incisors,  passing  under  a  lug  on  a  collar. 

E.  An  appliance  with  a  long  finger-spring  for  moving  incisors  outward. 
To  the  end  of  the  spring  is  soldered  an  additional  spring  for  lengthening  it. 

F.  An  apparatus  with  a  palatine  base-wire  for  moving  incisors  outward 
and  expanding  laterally  the  anterior  part  of  the  arch.  After  the  incisors 
are  moved  outward  by  the  finger-spring  the  anchorage  portions  are  bent  outward, 
effecting  the  lateral  expansion. 


464 


Plate  IX 


Plate  X 


PLATE    X 
Incisors,  Upper,  to  move  Out-ward 

A.  An  api)lianre  with  a  palatine  base-wire.  To  the  anterior  portion  of  the 
anchorage  is  attached  a  curved  finger-spring  for  moving  the  incisors  outward. 

B.  An  appliance  with  a  curved  finger-spring  and  a  palatine  spring  base-wire 
with  a  U-shaped  loop  in  the  centre.  After  the  incisors  are  moved  outward  with 
the  finger-spring,  the  loop  is  broadened  gradually  for  the  lateral  expansion 
of  the  arch. 

C.  A  palatine  base-wire  located  in  the  distal  part  of  the  arch  with  the  ends 
projecting  forward  in  the  anchorage  portions.  To  the  front  of  the  anchorage  on 
each  side  is  attached  a  curved  finger-spring  for  moving  the  incisors  outward. 
The  anchorage  portions  are  then  bent  outward  for  expanding  the  arch  laterally. 

D.  An  appliance  with  finger-springs  for  moving  outward  lateral  incisors  and 
cuspids. 

E.  A  device  with  a  rigid  palatine  base-wire  and  two  long  curved  finger- 
springs  for  moving  incisors  outward. 

F.  A  palatine  base-wire  with  curved  finger-springs.  The  anchorage 
consists  of  spring-clasp  attachments  and  wire-clasps. 


46.T 


PLATE    XI 
Incisors,  Upper,  to  move   Outward 

A.  A  device  with  a  palatine  base-wire  and  semicircular  spring  with  loops  for 
moving  incisors  outward.  The  spring  is  retained  by  collars  with  lugs  cemented 
to  the  incisors. 

B.  A  palatine  base-wire  and  semicircular  spring  with  loops,  anchored 
by  partial-clasps  and  wire-clasps  around  the  deciduous  molars. 

C.  A  device  with  a  semicircular  spring  and  loops.  The  base-wire  is 
arranged  to  cross  the  distal  part  of  the  arch.  When  the  incisors  were  moved 
outward,  the  anchorage  portions  were  bent  slightly  outward  for  expanding 
the  arch  laterally. 

D.  An  appliance  with  a  palatine  base-wire  and  semicircular  spring.  The 
anchorage  is  arranged  to  include  several  teeth.      Generally  this  is  essential. 

E.  A  palatine  base-wire  and  semicircular  spring  for  moving  incisors  out- 
ward, anchored  by  spring-clasp  attachments  and  a  finger-spring  extending  from 
either  side. 

F.  A  palatine  base-wire  and  semicircular  spring  with  loops.  To  the  spring 
was  soldered  a  wire  clip  to  rest  on  the  distal  surface  of  a  cuspid  for  moving  it 
forward  at  the  time  the  incisors  were  moved  outward. 


466 


Plate  XI 


B 


Plate  XII 


D 


PLATE    XII 

Incisors,  Upper,  to  move   Outward 

A.  An  appliance  with  a  palatine  base-wire  located  back  in  the  arch.  To 
the  anchorage  in  the  anterior  part  is  attached  the  ends  of  a  semicircular  spring 
with  U-shaped  loops.  The  spring  is  held  in  position  on  the  incisors  with  collars 
and  lugs.  Two  finger-springs  are  also  attached,  one  on  either  side,  for  moving 
outward  the  first  l)icusiiids. 

B.  A  strong  palatine  base-wire  supporting  a  semicircular  spring  with  loops, 
and  also  two  springs  for  moving  bicuspids  outward  and  backward. 

C.  A  palatine  base-wire  anchored  to  the  second  bicuspids  and  molars. 
Springs  are  attached  on  either  side  for  moving  the  first  bicuspids  backward,  or 
forward,  as  the  incisors  are  moved  outward. 

D.  An  appliance  with  a  palatine  base-wire  and  semicircular  spring  strongly 
anchored.  A  secondary  spring  is  attached  to  the  front  of  the  semicircular  spring 
for  moving  the  cuspids  outward  with  the  incisors. 

E.  An  apparatus  with  a  palatine  base-wire.  A  semicircular  spring  with 
U-shaped  loops  and  a  finger-spring  are  attached  for  moving  outward  a  central  and 
lateral  incisors  and  a  cuspid  on  one  side  of  the  arch  that  had  a  lingual  occlusion. 
The  anchorage  portions  were  built  up  for  opening  the  bite. 

F.  A  device  with  a  palatine  base-wire  and  a  semicircular  spring  with 
complete  or  circular  loops  for  moving  incisors  outward.  Two  finger-springs  are 
also  attached  for  moving  inward  prominent  cuspids. 


467 


PLATE    XIII 
Incisors,  Upper,  to  move  Outward,  to  move   Outward  Bodily 

A.  An  appliance  for  increasing  the  space  and  moving  outward  an  incisor 
when  there  is  a  close  bite.  It  is  made  with  a  labio-buccal  spring  base-wire 
having  a  U-shaped  loop.  To  the  base-wire  is  attached  a  spring,  bent  twice  at 
right  angles  with  tlie  width  between  the  parallel  arms  equal  to  the  width  of  the 
tooth.  These  pass  over  the  arch  and  the  ends  are  bent  towards  each  other  to 
rest  on  the  lingual  side.  Force  is  caused  by  curving  the  ends  of  the  spring 
closer  to  the  base-wire  a  little  at  a  time. 

B.  An  inclined  plane  attached  to  a  lingual  base-wire.  It  was  applied 
in  the  lower  arch  for  moving  outward  an  upper  incisor. 

C.  A  device  with  a  palatine  base-wire  and  semicircular  spring  with  loops. 
The  spring  is  retained  by  lugs  on  collars  cemented  to  the  incisors  to  be  moved. 

D.  An  appliance  with  two  finger-springs  for  moving  incisors  outward.  The 
arch  was  expanded  laterally  by  bending  outward  the  ends  of  the  base-wire. 

E.  An  apparatus  for  moving  incisors  outward  bodily.  Two  looped  springs 
are  attached  in  the  anchorage,  with  the  ends  shaped  to  rest  against  spurs 
for  moving  forward  a  sliding  lingual  base-wire.  The  front  of  the  base-wire 
passed  between  two  horizontal  planes  soldered  to  the  lingual  side  of  a  metal  cap 
that  was  cemented  to  the  incisors. 

F.  An  appliance  for  the  outward  bodily  movement  of  the  incisors.  After 
the  incisors  were  moved  outward  the  arch  was  expanded  laterally  by  opening  the 
U-shaped  loop  in  the  palatine  spring  base-wire. 


468 


Plate  XIII 


/v 


Plate  XIV 


PLATE    XIV 

Incisors,  Lower,  to  move   In\vard 

A.  A  lingual  base-wire  anchored  by  spring-clasp  attachments  and  pieces  of 
plate-metal  projecting  forward  to  rest  on  the  lingual  faces  of  the  laterals.  A 
curved  spring  is  attached  on  one  side  shaped  to  pass  over  the  arch  following 
the  labial  curve  to  cause  force  on  prominent  incisors. 

B.  A  device  with  a  lingual  base-wire,  and  two  finger-springs  extending  over 
the  arch  to  force  inward  prominent  front  teeth. 

C.  A  lingual  base-wire  anchored  by  spring-clasp  attachments  in  the  distal 
part  of  the  arch.  To  the  base-wire  in  the  front  are  attached  pieces  of  plate-metal 
for  strengthening  the  anchorage.  Additional  partial-clasps  should  be  employed. 
Force  for  moving  inward  the  incisors  is  got  by  a  labial-spring  with  U-shaped 
loops  passing  over  the  arch  to  be  attached  to  the  base-wire. 

D.  An  appliance  with  metal  extending  on  to  the  grinding  surface  of  the 
anchorage  teeth  for  opening  the  bite.  To  the  anterior  part  is  attached  a  semicir- 
cular spring  with  loops  for  moving  inward  lower  incisors  that  had  a  labial 
occlusion. 

E.  An  apparatus  with  a  lingual  base-wire  and  semicircular  spring  with  loops 
for  moving  inward  incisors  and  cuspids.  Additional  force  was  caused  on  the 
cuspids  by  curved  finger-springs  extending  from  the  base-wire,  one  on  either 
side  to  rest  on  their  mesio-labial  surface. 

F.  A  lingual  base-wire,  and  a  semicircular  spring  passing  in  front  of  the 
incisors  and  cuspids  for  moving  them  inward.  The  loops  of  the  spring  were 
arranged  to  rest  inside  of  the  arch  between  the  base-wire  and  the  gum. 


469 


PLATE    XV 
Incisors,  Upper,  to  move  Inward 

A.  An  appliance  with  a  double-curved  spring  shaped  to  pass  over  the  arch 
and  rest  on  the  labial  side  of  a  prominent  incisor  for  forcing  it  inward. 

B.  An  appliance  with  a  lingual  base-wire,  and  spring  for  moving  inward  a 
prominent  incisor,  at  the  same  time  retaining  teeth  on  the  sides  of  the  arch  that 
had  been  moved  outward. 

C.  A  lingual  base-wire  with  a  double-armed  spring  attached  to  the  anterior 
part.  The  arms  of  the  spring  are  passed  over  the  arch  either  side  of  a  prominent 
incisor  at  the  junction  with  the  adjoining  teeth,  with  the  ends  bent  towards  each 
other  to  rest  on  the  labial  side  for  forcing  the  tooth  inward. 

D.  An  appliance  with  a  lingual  base-wire  ;  the  ends  are  formed  to  enter  the 
centre  of  the  anchorage.  To  the  anterior  part  of  the  base-wire  is  attached  plate- 
metal  shaped  to  the  circle  it  is  desired  the  incisors  shall  assume.  To  the  plate- 
metal  is  attached  a  double-curved  spring  extending  over  the  arch  at  the  median 
line  and  resting  on  the  labial  side  of  the  incisors.  Action  of  the  spring  is 
caused  by  bending  the  end  backward.  The  arch  is  expanded  laterally  by 
bending  outward  the  ends  of  the  base-wire. 

E.  A  device  with  a  palatine  base-wire.  To  the  anterior  part  of  the  anchor- 
age is  attached  a  spring  shaped  to  pass  over  the  arch  at  the  junction  of  the  teeth 
to  the  buccal  side,  then  forward  to  rest  on  the  labial  faces  of  the  incisors  for 
forcing  them  inward. 

F.  A  palatine  base-wire  with  a  finger-spring  passing  to  the  front  of  the 
incisors.  For  anchorage,  wire-clasps  are  used  on  one  side  of  the  arch  and 
spring-clasps  on  the  other. 


470 


Plate  XV 


Plate  XVI 


PLATE    XVI 
Incisors,  Upper,  to  move  Inward 

A.  An  appliance  with  a  palatine  spring  base-wire  in  the  form  of  a  loop.  To 
the  anchorage  is  attached  a  finger-spring,  shaped  to  pass  over  the  arch  to  the 
buccal  side,  then  to  extend  forward  following  the  labial  curve  of  tiie  tet-th  to  the 
opposite  side  of  the  arch.  The  incisors  are  moved  inward  by  reshaping  the 
spring  from  time  to  time.  When  required,  the  arch  is  expanded  by  opening  the 
loop  of  the  base-wire. 

B.  A  palatine  base-wire,  with  a  finger-spring  attached  to  the  anterior  part 
of  the  anchorage,  shaped  to  extend  to  the  opposite  side  of  the  arch  following  the 
labial  cur^^e.  To  the  free  end  of  the  spring  is  soldered  a  piece  of  plate-metal 
bent  into  an  S-shape  for  hooking  over  the  edge  of  one  or  more  of  the  incisors  to 
prevent  the  spring  from  pressing  against  the  gum  as  force  is  applied.  A  spring 
with  a  partial-clasp  is  attached  on  the  opposite  side  of  the  arch  for  moving 
outward  a  first  bicuspid. 

C.  A  lingual  ])ase-wire  with  a  spring  attached  on  either  side  of  the  arch, 
shaped  to  extend  to  the  buccal  side,  then  forward  to  move  prominent  incisors 
and  cuspids  inward. 

D.  An  appliance  with  a  lingual  base-wire,  and  semicircular  spring  with  loops 
for  moving  inward  four  incisors. 

E.  A  lingual  base-wire  and  semicircular  spring  with  loops  used  for  moving 
inward  six  front  teeth.  The  anchorage  should  generally  be  strengthened  by 
additional  partial-clasps. 

F.  A  palatine  base-wire  with  semicircular  spring  and  U-shaped  loops 
for  moving  inward  six  upper  teeth.  The  loops  are  arrang^-d  to  extend  upward 
under  the  lip.  Action  is  effected  by  closing  the  loops  a  little  at  a  time.  The 
anchorage  is  fortified  by  extending  wire-clasps  to  the  distal  side  of  partially 
erupted  molars. 

471 


PLATE    XVII 

Incisors,  Upper,  to  move  Inward 

A.  An  appliance  with  a  semicircular  spring  and  U-shaped  loops  for  reducing 
upper  anterior  protrusion  before  the  eruption  of  the  first  bicuspids.  It  was 
anchored  to  the  first  permanent  molars  and  second  bicuspids. 

B.  A  device  with  a  semicircular  spring  and  U-shaped  loops  for  moving 
inward  the  six  front  teeth,  the  first  bicuspids  having  been  extracted.  It  was 
anchored  to  the  second  bicuspids,  first  and  second  molars.  Action  was  caused 
by  closing  the  loops  of  the  spring  slightly  at  a  time. 

C.  An  apparatus  for  moving  inward  incisors,  at  the  same  time  expanding 
laterally  the  anterior  part  of  the  arch.  A  palatine  base-wire  is  arranged 
to  cross  the  distal  part  of  the  arch  where  it  is  broad  enough.  To  the  anchorage 
on  each  side  is  attached  one  end  of  a  semicircular  spring  with  U-shaped  loops. 
The  loops  are  closed  for  forcing  the  incisors  inward,  and  the  front  part  of  the 
anchorage  is  bent  outward  for  expanding  the  arch  as  required. 

D.  A  palatine  base-wire  is  arranged  to  cross  the  distal  part  of  the  arch,  with 
the  ends  extending  forward  in  the  anchorage  portion  for  anterior  lateral  expansion  ; 
at  the  same  time  prominent  incisors  are  moved  inward  by  a  semicircular  spring. 

E.  An  apparatus  with  a  lingual  base-wire,  used  for  moving  inward  promi- 
nent incisors  and  cuspids.  It  was  strongly  anchored.  The  incisors  were 
moved  inward,  at  the  same  time  rotating  them  by  a  semicircular  spring  with 
U-shaped  loops,  arranged  to  cross  the  labial  faces  of  the  incisors  with  the  ends 
extending  over  the  arch  to  be  attached  to  the  base-wire.  The  cuspids  were 
moved  inward  by  finger-springs. 

F.  A  device  with  a  lingual  base-wire  and  springs,  used  for  moving  inward 
incisors,  at  the  same  time  moving  inward  and  backward  prominent  cuspids. 


472 


Plate  XVII 


Plate  XVIII 


PLATE    XVIII 

Incisors,  Upper,  to  move  In\vard 

A.  An  appliance  with  a  palatine  base-wire  and  semicircular  spring  for 
moving  incisors  inward.  Action  is  caused  by  closing  the  loops  of  the  spring. 
Two  finger-springs  are  attached  in  the  anterior  part  of  the  anchorage  to  rest  on 
the  lingual  side  of  the  incisors  for  evening  them. 

B.  A  device  with  both  a  palatine  and  a  lingual  base-wire.  A  semicircular 
spring  is  arranged  to  move  the  incisors  inward  and  to  rotate  them  by  forcing 
them  against  the  lingual  base-wire. 

C.  An  appliance  for  moving  inward  prominent  incisors  and  rotating  them, 
made  with  a  lingual  and  a  palatine  base-wire,  and  a  semicular  spring  with 
U-shaped  loops.  To  the  lingual  base-wire  is  attached  a  thin  piece  of  plate- 
metal,  suitably  shaped  to  project  forward  and  rest  on  the  lingual  side  of  the 
teeth  for  evening  them  as  pressure  is  caused  by  the  spring. 

D.  A  device  with  a  lingual  and  a  palatine  base-wire  for  moving  incisors 
inward  and  rotating  them.      It  has  a  partial-clasp  fitted  to  each  of  the  teeth. 

E.  A  T  attached  to  a  semicircular  spring  with  U-shaped  loops  resting  over 
the  palatine  arch. 

F.  An  appliance  with  a  semicircular  spring  and  U-shaped  loops.  The 
spring  is  arranged  to  rest  on  the  labial  faces  of  the  incisors  and  pass  to  the  lingual 
side,  where  the  ends  of  the  loops  are  attached  to  the  ancjiorage. 


47S 


PLATE    XIX 
Incisors,  Rotation  of 

A.  An  upper  appliance  with  a  lingual  base-wire  ;  a  double-curved  spring  is 
attached  to  the  anterior  part  arranged  to  pass  over  the  arch  and  rest  on  the 
labial  side  of  an  incisor  for  forcing  it  against  the  base-wire  and  rotating  it. 

B.  A  lower  appliance  with  a  lingual  base-wire  and  spring.  The  spring  is 
shaped  to  extend  over  the  arch  and  press  inward  on  an  incisor  for  its  rotation. 

C.  Two  springs,  anchored  by  spring-clasp  attachments.  Each  is  used 
independently  for  the  rotation  of  a  tooth  in  connection  Avith  a  tube  and  collar. 
The  one  on  the  left  side  is  shaped  to  the  labial  side  of  the  arch,  and  the  one  on 
the  right  for  the  lingual  side. 

D.  Two  lingual  springs  used  in  connection  with  a  collar  and  tube  for 
the  rotation  of  the  incisors.  One  of  them  is  provided  with  a  U-shaped  loop  to 
assist  in  adjustment. 

E.  Two  lingual  springs  with  U-shaped  loops  supported  by  spring-clasp 
attachments.  The  free  ends  of  the  springs  are  bent  into  hooks  to  engage  with 
eyelets  on  the  mesio-lingual  or  disto-lingual  sides  of  collars  cemented  to 
the  incisors  to  be  rotated. 

F.  A  lingual  base-wire,  to  the  anterior  of  which  is  attached  two  small 
looped  springs  arranged  to  hook  into  eyelets  on  the  disto-lingual  side  of  collars 
cemented  to  the  central  incisors  for  rotating  them. 


474 


Plate  XIX 


Plate  XX 


D 


PLATE    XX 
Incisors,  Rotation  of 

A.  A  device  for  the  upper  arch  with  a  lingual  base-wire  well  anchored. 
To  the  front  of  the  base-wire  is  attached  a  piece  of  sheet-metal  projecting 
forward  to  rest  on  the  lingual  side  of  the  incisors.  To  this  a  spring-wire 
is  attached,  shaped  properly  to  pass  over  the  arch  at  the  junction  of  the  teeth, 
and  bent  at  an  acute  angle  to  rest  on  the  labial  side  of  an  incisor  for  moving  it 
inward  and  rotating  it. 

B.  An  apparatus  similar  to  the  one  described.  A  spring  is  attached  to  the 
metal  in  the  anterior  part  for  rotating  and  moving  incisors  inward. 

C.  A  base-wire  with  a  finger-spring  on  either  side  shaped  to  extend  over  the 
arch  and  project  forward  in  a  curve  to  rotate  and  move  inward  prominent  lateral 
incisors. 

D.  A  base-wire  with  plate-metal  attached  to  the  anterior  part.  A  semicir- 
cular looped  spring  is  arranged  to  force  the  teeth  against  the  metal  for  rotation, 
and  to  even  them. 

E.  An  appliance  for  rotating  lateral  incisors  by  causing  pressure  on  the 
labial  and  lingual  sides.  To  the  anterior  part  of  the  base-wire  are  attached 
short  projecting  strips  of  plate-metal  to  rest  on  the  lingual  side  of  the  teeth, 
and  similar  projecting  pieces  are  attached  to  a  semicircular  spring  to  press  on  the 
labial  side. 

F.  A  device  with  a  lingual  and  a  palatine  base-wire  strongly  anchored. 
A  curved  piece  of  metal  is  attached  to  the  anterior  part  of  the  base-wire  shaped 
in  the  circle  it  is  desired  the  teeth  shall  assume  when  regulated.  A  semicircular 
spring  with  loops  is  arranged  to  press  the  incisors  against  the  metal  for  their 
rotation. 


475 


PLATE    XXI 

Incisors,  Rotation  of 

A.  An  appliance  with  a  lingual  base-wire,  to  the  anterior  part  of  which  is 
soldered  two  clips  arranged  to  press  on  the  lingual  side  of  the  lateral  incisors. 
A  finger-spring  is  attached  to  the  base-wire  on  one  side,  shaped  to  extend 
outward  and  forward  in  a  curve  to  the  front  of  the  arch,  where  it  presses 
the  incisors  against  the  metals  rotating  them.  A  short  finger-spring  is  also 
attached  to  the  base-wire  on  the  opposite  side  for  moving  inward  a  prominent 
cuspid. 

B.  To  the  anterior  part  of  a  lingual  base-wire  several  strips  of  spring  plate- 
metal  are  attached,  arranged  to  rest  on  the  lingual  side  of  the  irregular  teeth.  A 
semicircular  spring  forces  the  teeth  inward  against  the  metals,  the  latter  being 
shaped  or  bent  to  rotate  the  teeth. 

C.  A  lingual  base-wire  with  a  broad  piece  of  plate-metal  attached  to  the 
anterior  part,  arranged  to  rest  on  the  lingual  side  of  some  of  the  teeth  to  assist  in 
their  rotation.  A  long  finger-spring  is  attached  to  the  base-wire  on  one  side, 
shaped  to  project  over  the  arch  and  extend  forward  to  rest  on  the  irregular  teeth 
for  forcing  them  against  the  metal.  This  reduced  the  rotated  condition  and 
forced  some  of  the  teeth  backward  in  the  line  of  the  arch. 

D.  A  device  with  plate-metal  attached  to  the  anterior  part  of  the  base-wire. 
On  one  side  is  soldered  two  finger-springs,  one  of  them  for  pressing  the 
incisors  against  the  metal  evening  them,  and  the  other  for  moving  inward 
and  backward  a  prominent  cuspid. 

E.  An  appliance  with  a  lingual  and  a  palatine  base-wire  anchored  with 
spring-clasp  attachments  over  the  second  bicuspids.  To  the  anterior  part  of  the 
lingual  base-wire  a  T  was  attached  which  passed  between  the  central  incisors  and 
pressed  on  their  labial  faces  for  rotating  and  retaining  them. 

F.  A  T-device  with  a  lingual  and  a  palatine  base-wire  strongly  anchored, 
made  similar  to  the  one  previously  described. 

476 


Plate  XXI 


Plate  XXII 


PLATE    XXII 
Incisors,  to  move  Laterally 

A.  An  appliance  with  a  lingual  base-wire  and  two  finger-springs  for  moving 
incisors  laterally  towards  each  other. 

B.  A  device  with  a  palatine  base-wire  and  semicircular  spring  with  loops. 
To  the  anterior  part  of  the  semicircular  spring  is  attached  a  curved  spring  with 
arms  to  move  the  incisors  towards  each  other. 

C.  An  appliance  with  a  palatine  base-wire.  A  spring  is  attached  in  the 
anchorage  on  one  side  with  a  U-shaped  loop  made  to  rest  at  the  median 
line.  The  free  end  of  the  spring  was  bent  into  a  curve  to  rest  back  of  the  lateral 
incisor  for  moving  it  and  the  central  incisor  towards  the  medium  line  closing  a 
broad  interdental  space. 

D.  An  apparatus  that  was  used  for  moving  incisors  together  closing  a  broad 
interdental  space,  at  the  same  time  the  bicuspids  were  moved  forward  by  closing 
the  U-shaped  loops  in  the  semicircular  spring. 

E.  Shows  an  appliance  with  a  spring  of  plate-metal  attached  to  a  lingual 
base-wire.     Action  is  caused  by  separating  the  ends  of  the  spring. 

F.  A  lingual  base-wire  with  gold  springs  attached  for  spacing  and  evening 
the  teeth,  at  the  same  time  supporting  an  artificial  tooth. 


477 


PLATE    XXIII 
Cuspids,  to  move   Outward 

A.  For  moving  outward  two  cuspids,  a  collar  with  a  lug  on  the  lingual 
side  is  cemented  to  each.  A  small  spring  is  bent  into  three  U-shaped  loops 
of  sufficient  width  to  pass  under  the  lugs.  The  ends  of  the  spring  are  shaped 
to  extend  backward  on  each  side  of  the  arch  to  be  anchored  with  spring-clasp 
attachments.     Action  is  effected  by  opening  the  U-shaped  loops  by  bending. 

B.  An  appliance  with  a  lingual  base-wire  for  moving  outward  a  cuspid. 
Two  springs  are  attached  to  the  base-wire,  each  shaped  to  cause  force  for 
its  movement. 

C.  An  appliance  with  a  palatine  base-wire.  A  finger-spring  extends  forward 
from  the  anchorage  on  one  side  to  pass  under  a  lug  on  a  collar  cemented  to  the 
cuspid  to  be  moved. 

D.  A  device  with  a  broad  palatine  base-wire.  A  finger-spring  is  attached  in 
the  anchorage  on  each  side  of  the  arch,  formed  to  pass  under  a  lug  on  a  collar 
cemented  to  each  of  the  cuspids. 

E.  An  appliance  is  shown  with  a  lingual  base-wire  arranged  for  expanding 
the  lower  arch.  To  the  anchorage  on  each  side  is  soldered  a  finger-spring, 
shaped  to  extend  forward  and  pass  under  a  lug  for  moving  outward  the  cuspids. 

F.  A  jack-screw  device  is  shown  for  moving  a  cuspid.  The  anchorage 
with  partial-clasps  and  spring-clasp  attachments  can  be  made  to  include  all 
of  the  teeth  on  one  side  of  the  arch.  To  the  anchorage  is  soldered  the  nut  of 
the  jack-screw.  The  other  end  is  anchored  in  a  socket  on  a  collar  cemented  to 
the   cuspid  to   be   moved. 

A  device  with  two  looped  springs  is  also  shown.  It  is  anchored  to  a  bicuspid 
on  one  side  of  the  arch.  The  front  spring  is  arranged  to  move  outward  a  cuspid, 
as  the  other  draws  inward  a  bicuspid.  The  ends  are  retained  by  eyelets  on 
collars  cemented  to  the  teeth. 

478 


Plate  XXIII 


D 


Plate  XXIV 


PLATE    XXIV 

Cuspids,  Lower,  to  move  Inward 

A.  An  appliance  with  a  lingual  base-wire  and  a  double-curved  spring,  used 
several  years  since  for  moving  inward  a  right  lower  cuspid.  The  spring  is 
arranged  to  extend  over  the  arch  at  the  junction  of  the  teeth  to  rest  on  the  mesio- 
labial  surface.     Additional  partial-clasps  for  anchorage  should  be  employed. 

B.  A  lingual  base-wire  device,  with  a  spring  for  forcing  a  partially  erupted 
cuspid  into  the  circle  of  the  arch. 

C.  A  lingual  base-wire  with  a  spring  fur  moving  into  line  an  erupting  left 
cuspid. 

D.  An  appliance  with  a  finger-spring  used  for  moving  inward  a  very  promi- 
nent cuspid. 

E.  An  apparatus  with  one  curved  spring  and  one  looped  spring  for  moving 
inward  both  lower  cuspids. 

F.  A  lingual  base-wire  strongly  anchored  with  two  curved  springs  moving 
the  lower  cuspids  inward. 


479 


PLATE    XXV 
Cuspids,  to  move  Inward 

A.  A  device  anchored  on  one  side  of  the  arch,  with  a  spring  formed  into  a 
U-shaped  loop  at  the  median  line.  The  spring  extends  to  the  opposite  side  of 
the  arch,  passing  over  at  the  junction  of  the  teeth  and  curved  to  rest  on  the  labial 
side  of  the  cuspid  where  it  is  attached  to  a  carefully  fitted  partial-clasp  for 
retaining  it.  Action  is  caused  by  changing  the  shape  of  the  spring  closing 
the  loop  as  required. 

B.  An  appliance  similar  to  the  one  previously  described,  except  that  the  end 
of  the  spring  is  shaped  into  a  complete  U-shaped  loop,  the  lateral  arms  passing 
either  side  of  the  prominent  cuspid  with  the  free  end  terminating  on  the  lingual 
side  of  the  first  bicuspid.  The  space  in  the  arch  for  the  cuspid  is  increased  by 
broadening  this  loop,  after  which  the  cuspid  is  moved  inward  by  closing 
the  loop  at  the  median  line. 

C.  A  lingual  base-wire  with  a  looped  spring  attached.  The  spring  was 
arranged  to  pass  either  side  of  a  prominent  cuspid  to  the  buccal  side,  where  it 
crossed  the  cuspid  at  the  gum  line.  The  opening  of  the  loop  increased  space 
for  the  movement  of  the  cuspid,  while  curving  the  end  of  the  loop  towards  the 
base-wire  forced  it  inward. 

D.  A  lingual  base-wire  with  a  spring  attached  at  the  median  line  formed 
into  two  U-shaped  loops,  one  projecting  into  the  palatine  arch  and  the  other 
passing  over  the  arch  to  the  buccal  side,  where  it  rested  on  the  prominent  cuspid 
at  the  gum  line.  Space  for  the  cuspid  was  increased  by  opening  this  loop,  and 
force  for  moving  it  inward  was  effected  by  changing  the  palatine  loop. 

E.  An  appliance  with  two  springs  used  for  moving  prominent  cuspids 
inward  and  backward. 

F.  A  strongly  anchored  device  arranged  for  moving  inward  and  backward 
prominent  cuspids. 

480 


Plate  XXV 


D 


Plate  XXVI 


PLATE    XXVI 
Cuspids,  to  move  Inward 

A.  An  appliance  witli  a  lingual  base-wiro  and  two  curved  springs  for 
moving  cuspids  inward.  Also  two  finger-springs  extend  forward  from  the 
anchorage  for  forcing  the  incisors  outward. 

B.  A  lingual  base-wire  with  plate-metal  attached  to  the  anterior  portion  to 
assist  the  anchorage  and  even  the  teeth.  Two  long  finger-springs  extend 
laterally  from  the  base-wire  to  the  buccal  side,  then  forward  to  rest  on  the 
mesio-labial  side  of  the  prominent  cuspids,  for  moving  them  and  the  bicuspids 
inward  and  backward. 

C.  A  device  with  a  long  finger-spring  extending  from  the  base-wire  over  the 
arch  to  the  buccal  side  for  moving  inward  a  prominent  cuspid.  A  clip  was 
attached  to  the  base-wire  and  shaped  to  extend  on  to  the  grinding  surface  of 
a  bicuspid  to  prevent  the  appliance  from  pressing  on  the  gum. 

D.  An  appliance  with  two  finger-springs  of  different  shape,  one  extending 
forward  in  a  curve,  the  other  passing  from  the  base-wire  over  the  arch  in  front 
of  the  prominent  cuspid,  with  the  end  shaped  to  cross  it  at  the  gum  line. 

E.  An  apparatus  with  a  double  palatine  base-wire  and  two  springs  attached. 
The  base-wire  is  shaped  similar  to  a  loop,  each  pointing  in  an  opposite  direction. 
This  arrangement  gave  rigidity  to  the  appliance  and  facilitated  the  expansion 
of  the  arch.  One  spring  passed  over  at  the  junction  of  the  teeth  to  the 
labial  side  for  moving  the  prominent  cuspid  and  lateral  inward.  The  lingual 
spring  was  shaped  to  force  outward  the  central  incisor  for  evening  them. 

F.  A  palatine  base-wire  is  strongly  anchored.  Two  finger-springs  are 
attached  for  moving  prominent  cuspids  inward,  and  a  semicircular  spring  with 
U-shaped  loops  arranged  for  moving  outward  the  incisors. 


481 


PLATE    XXVII 
Cuspids,  to  move  Inward  and  Backward 

A.  An  appliance  with  a  lingual  base-wire.  A  finger-spring  extends  to  the 
buccal  side  and  forward  for  moving  inward  a  prominent  cuspid.  A  finger-spring 
is  attached  to  the  base-wire  on  the  opposite  side  of  the  arch  following  the 
lingual  curve  towards  the  prominent  cuspid  for  moving  outward  an  instanding 
lateral  and  central  incisor. 

B.  A  lingual  base-wire  device  with  springs  attached  for  moving  cuspids 
inward  and  backward.  This  form  of  anchorage  with  wire-clasps  projecting 
backward  to  rest  on  the  distal  surface  of  the  second  molars  is  an  advantage  when 
the  second  molars  are  erupting  and  more  anchorage  is  required,  as  the  ends  of 
the  clasps  can  be  bent  to  rest  more  towards  the  necks  of  the  teeth. 

C.  A  lingual  base-wire  with  several  springs  attached  for  moving  inward 
prominent  cuspids  and  a  prominent  first  bicuspid,  at  the  same  time  moving 
outward  some  of  the  incisors. 

D.  An  appliance  with  double  springs  for  moving  prominent  cuspids  inward 
and  backward,  and  a  finger-spring  for  moving  inward  and  evening  the  incisors. 

E.  A  device  with  a  long  finger-spring  shaped  to  hook  over  a  pin  on  a  collar 
for  the  elevation  of  an  impacted  cuspid  or  for  moving  it  backward  or  forward 
for  encouraging  its  eruption.  If  used  for  the  former  purpose,  two  or  more  clips 
should  extend  from  the  base-wire  to  rest  on  the  morsal  surface  of  some  of  the 
adjoining  teeth,  to  prevent  the  appliance  from  pressing  on  the  gum. 

F.  A  device  with  a  spring  properly  curved  to  pass  under  the  gum  to  move  a 
partially  erupted  prominent  cuspid  backward  and  inward. 


482 


Plate  XXVII 


Plate  XXVIII 


D 


PLATE    XXVIII 

Cuspids,  to  move  Inward  and  Backward 

A.  An  appliance  with  a  palatine  base-wire.  From  the  lingual  anchorage 
short  looped  finger-springs  extend  over  the  arch  for  forcing  prominent  cuspids 
inward. 

B.  A  palatine  and  a  lingual  base- wire  device  with  a  clip  attached  to 
the  anterior  part  shaped  to  prevent  the  lateral  incisor  being  pressed  out  of 
position  as  the  cuspid  is  forced  inward  by  a  curved  spring. 

C.  A  lingual  base-wire  with  flanges  or  inclined  planes  attached  to  rest 
against  the  lateral  incisors  for  moving  them  outward,  as  a  prominent  cuspid 
is  being  moved  inward  and  backward,  and  a  bicuspid  moved  outward  on  the 
opposite  side  of  the  arch. 

D.  A  device  with  plate-metal  attached  to  the  anterior  portion  of  a  lingual 
base-wire  to  assist  the  anchorage  for  moving  a  prominent  cuspid  inward. 

E.  A  lingual  base  wire  with  plate-metal  attached  to  the  anterior  part 
to  assist  the  anchorage  for  moving  a  prominent  cuspid  inward  without  crimping 
the  incisors. 

F.  An  appliance  with  a  palatine  base-wire  and  arms  projecting  inward 
to  rest  on  the  lingual  side  of  the  lateral  incisors  to  assist  the  anchorage  as  the 
cuspids  are  moved  inward  with  curved  springs. 


483 


PLATE    XXIX 
Cuspids,  to  move  Backward  in  the  Line  of  the  Arch 

A.  An  appliance  with  a  lingual  base-wire  used  for  moving  a  cuspid  and  two 
bicuspids  backward  in  the  line  of  the  arch.  A  clip  was  attached  to  the  anterior 
part  of  the  base-wire  to  assist  the  anchorage  and  prevent  the  appliance  from 
pressing  against  the  gum. 

B.  An  apparatus  with  a  long  finger-spring  attached  to  a  lingual  base-wire 
for  moving  backward  a  prominent  cuspid  and  two  bicuspids.  Two  pieces  of 
plate-metal  forming  inclined  planes  were  attached  to  the  anterior  part  of  the 
base-wire  to  assist  the  anchorage. 

C.  A  device  anchored  to  only  one  side  of  the  arch,  with  springs  attached 
for  moving  backward  a  cuspid  and  a  bicuspid. 

D.  An  appliance  with  a  lingual  base-wire  strongly  anchored  for  moving 
a  cuspid  and  two  bicuspids  backward. 

E.  A  lingual  base-wire  with  a  long  and  a  short  spring  attached  for  moving 
cuspids  backward.  Straight  springs  are  arranged  to  prevent  the  cuspids  being 
forced  inward  too  far. 

F.  A  cast  metal-plate  with  a  long  finger-spring  for  forcing  a  lower  cuspid 
and  two  bicuspids  backward. 


484 


Plate  XXIX 


Plate  XXX 


onro 


PLATE    XXX 
Bicuspids,  to  move  Outward. 

A.  A  lingual  spring  base-wire  that  was  used  for  moving  outward  two 
bicuspids  in  the  lower  arch.      It  is  suitable  for  retaining  the  teeth. 

B.  An  expanding  device  for  moving  outward  the  lower  bicuspids.  A 
lingual  base-wire  is  arranged  to  extend  backward  to  be  attached  in  the  anchorages 
which  project  forward.  With  this  arrangement  a  considerable  movement  can  be 
brought  about. 

C.  A  palatine  spring  base-wire  with  arms  shaped  to  project  forward,  and 
retained  by  spring-clasp  attachments  passing  over  the  bicuspids  to  be  moved. 
Action  is  caused  by  bending  outward  the  lateral  arms. 

D.  An  appliance  anchored  to  several  teeth  on  one  side  of  the  arch  and  to 
one  tooth  on  the  other.  A  palatine  spring  base-wire  has  the  ends  bent  forward 
forming  arms  to  be  attached  in  the  anchorage.  Force  is  caused  by  bending  out- 
ward the  arms  a  little  at  a  time. 

E.  A  device  similar  to  the  one  described.  A  palatine  spring  base-wire  with 
arms  projecting  forward.  To  the  anterior  part  of  the  anchorage  is  attached 
a  semicircular  spring  with  two  U-shaped  loops  for  moving  incisors  outward. 

F.  A  device  with  a  palatine  spring  base-wire  in  the  form  of  a  U-shaped  loop 
for  moving  outward  a  bicuspid  on  each  side  of  the  arch. 


485 


PLATE    XXXI 

Bicuspids,  to  move  Outward,  and  Inward 

A.  A  lingual  base-wire  for  moving  outward  a  bicuspid.  A  spring  is 
attached  for  increasing  the  space  for  its  movement.  The  arms  of  the  spring 
extend  over  the  arch  where  the  ends  are  bent  outward  to  rest  on  the  buccal  side 
of  the  adjoining  teeth. 

B.  A  device  similar  to  the  one  described.  The  arms  of  the  spring  that  pass 
over  the  arch  are  separated  for  increasing  the  space  for  the  bicuspid,  and  the  ends 
are  curved  inward  to  press  on  the  buccal  side  of  the  adjoining  teeth  to  assist 
the  action  of  the  base-wire. 

C.  A  simple  spring  device  for  moving  outward  a  bicuspid.  A  partial-clasp 
is  fitted  to  one  side  of  the  tooth  to  be  moved.  A  spring  is  arranged  to  cross  the 
partial-clasp  to  which  it  is  finally  soldered.  The  arms  are  shaped  to  pass  over 
the  arch  and  the  ends  bent  outward  to  rest  on  the  adjoining  teeth.  They 
are  curved  inward  for  getting  force. 

D.  A  lingual  base-wire  anchored  to  the  bicuspids  not  to  be  moved.  A 
spring  is  attached  to  the  base-wire  extending  over  the  arch  like  an  arm  to  rest  on 
the  buccal  side  of  a  prominent  bicuspid  for  forcing  it  inward. 

E.  An  appliance  with  a  lingual  base-wire  for  moving  a  bicuspid  inward. 
To  the  base-wire  is  attached  a  spring,  with  the  ends  shaped  like  arms  to  extend 
over  the  arch  at  the  junction  of  the  teeth  either  side  of  the  bicuspid  to  the  gum 
line,  with  the  ends  bent  to  cross  the  buccal  surface.  Action  is  effected  by 
curving  the  ends  more  towards  the  base-wire. 

F.  A  lingual  base-wire  strongly  anchored.  A  spring  extends  from  either 
side  over  the  arch  at  the  junction  of  the  teeth  like  an  arm,  the  ends  crossing  the 
teeth  to  be  moved.  Pressure  is  caused  by  curving  the  ends  towards  the 
base-wire. 


486 


Plate  XXXI 


Plate  XXXII 


D 


PLATE   XXXII 

Bicuspids,  to  move  Backward,  to  move  Forward, 

to    relieve    Impaction 

A.  A  device  with  a  lingual  base-wire,  to  which  a  U-shaped  spring  is  attached 
on  either  side  of  the  arch  for  moving  bicuspids  backward. 

B.  An  appliance  with  U-shaped  springs  attached  to  a  lingual  base-wire  for 
moving  backward  the  bicuspids.  A  swaged  metal-cap  with  an  eyelet  soldered  on 
the  buccal  surface,  was  cemented  to  the  bicuspids  on  each  side  of  the  arch, 
to  provide  means  of  attachment  for  applying  supplemental  force  to  move 
the  teeth  bodily. 

C.  An  appliance  for  moving  bicuspids  forward.  A  palatine  and  a  lingual 
base-wire  is  strongly  anchored.  To  the  lingual  base-wire  is  soldered  curved 
finger-springs  to  rest  back  of  the  bicuspids  to  be  moved.  Force  is  applied 
by  bending  the  springs  forward  as  required. 

D.  An  apparatus  with  a  lingual  base-wire  and  looped  wire-springs,  anchored 
in  the  lower  arch  and  arranged  to  move  bicuspids  forward  in  the  upper  arch. 
The  springs  are  placed  at  an  angle  suitable  for  making  an  incline  to  pass  back  of 
each  of  the  upper  bicuspids  to  cause  force  on  them  in  occlusion. 

E.  An  appliance  for  causing  space  and  moving  outward  an  impacted 
or  instanding  bicuspid  at  the  same  time  forcing  a  prominent  cuspid  inward. 

F.  A  device  with  a  lingual  base-wire.  A  double-looped  spring  is  attached 
for  relieving  an  impacted  bicuspid. 


487 


PLATE    XXXIII 

Molars,  to  move  Backward,  Forward,  Outward,  Inward, 
Equalizing  the  Jaws,  Retaining 

A.  An  apparatus  with  two  palatine  base- wires,  one  of  them  strongly 
anchored  to  the  bicuspids  and  the  other  to  a  molar  on  each  side  of  the 
arch.  The  parts  are  connected  with  two  U-shaped  loops  of  spring-wire  for 
moving  the  first  molars  backward  in  the  line  of  the  arch.  It  is  applicable  for 
moving  the  molars  forward. 

B.  A  lingual  base-wire  spring  device  for  moving  molars  inward.  To  the 
base-wire  on  each  side  is  soldered  a  spring-wire  shaped  to  extend  over  the 
arch  to  rest  on  the  buccal  side  of  the  molars  to  be  moved,  near  the  gum. 
Action  is  caused  by  bending  the  springs  inward.  The  base-wire  is  strongly 
anchored  to  the  teeth  not  to  be  moved. 

C.  An  appliance  for  moving  molars  outward  or  an  impacted  molar  back- 
ward, righting  its  position. 

D.  An  equalizing  device.  A  lingual  base-wire  is  strongly  anchored.  At 
the  distal  part  of  each  end  an  inclined  plane  is  shaped  to  project  back  of  molars 
in  the  opposite  arch. 

E.  A  retaining  appliance  made  from  one  used  for  regulating  the  teeth.  The 
spring  was  made  rigid  by  attaching  the  free  end  to  the  base-wire. 

F.  A  lingual  base-wire  for  retaining,  anchored  on  each  side  of  the  arch  with 
spring-clasp  attachments. 


488 


Plate  XXXIII 


Plate  XXXIV 


PLATE    XXXIV 

Retaining 

A.  A  labio-buccal  base-wire  for  retaining  incisors  and  cuspids  that  have 
been  moved  inward.  The  ends  are  anchored  by  spring-clasp  attachments  over  a 
first  or  second  bicuspid  on  each  side  of  the  arch. 

B.  A  labio-buccal  base- wire  with  a  U-shaped  loop  arranged  to  rest  under 
the  lip  on  one  side  of  the  arch.  The  loop  is  of  advantage  in  permitting  desired 
changes. 

C.  A  device  with  a  labio-buccal  base-wire  and  two  U-shaped  loops,  anchored 
by  spring-clasp  attachments  over  the  bicuspids  ;  used  for  retaining  six  front  teeth 
that  have  been  moved  inward. 

D.  A  lingual  base-wire  strongly  anchored,  for  retaining  six  front  teeth  that 
had  been  moved  outward. 

E.  A  device  with  a  lingual  base-wire  for  retaining  teeth  that  have  been 
moved  outward,  with  a  spring  passing  over  the  arch  to  retain  a  tooth  that  had 
been  moved  inward.     Additional  partial-clasps  should  be  employed. 

F.  A  lingual  base-wire  used  for  retaining  teeth  on  the  sides  and  front  of  the 
arch  that  had  been  moved  outward.  A  finger-spring  is  attached  in  the  anchor- 
age for  retaining  two  teeth  that  had  been  moved  inward. 


489 


PLATE    XXXV 
Retaining 

A.  An  appliance  for  retaining  teeth  that  had  been  crimped,  some  of  them 
moved  outward,  others  moved  forward.  It  was  made  witli  a  lingual  base-wire 
and  a  semicircular  spring  with  U-shaped  loops,  the  ends  of  which  were  attached 
to  the  spring-clasps. 

B.  An  apparatus  used  for  retaining  incisors  and  cuspids  that  had  been 
moved  forward. 

C.  A  lingual  base-wire  with  plate-metal  attached  to  the  anterior  part  for 
retaining  lower  incisors  that  had  been  moved  outward  and  rotated. 

D.  A  lower  retainer  that  was  used  for  supporting  bicuspids  and  molars  that 
had  been  moved  outward. 

E.  A  device  used  for  retaining  teeth  after  the  expansion  of  the  arch. 

F.  An  appliance  with  a  palatine  and  a  lingual  base-wire.  The  latter  was 
fitted  to  the  teeth  to  retain  them. 


'490 


Plate  XXXV 


Plate  XXXVI 


c^"^^     c/x) 


PLATE    XXXVI 
Retaining 

A.  An  appliance  used  for  retaining  bicuspids  that  had  been  moved  inward. 

B.  A  device  with  a  lingual  base-wire  and  labial-spring  for  retaining  incisors 
that  had  been  rotated. 

C.  A  lower  appliance  used  for  retaining  incisors  that  had  been  crimped. 

D.  A  cast-metal  retainer  for  supporting  the  teeth  of  the  lower  arch,  made 
similar  to  one  described  by  Dr.  Richardson. 

E.  A  device  with  a  lingual  base-wire  for  retaining  lower  teeth  loosened  from 
pyorrhoea  alveolaris.  It  was  anchored  to  the  bicuspids  with  a  continuous, 
partial-clasp  fitting  the  lingual  side  of  the  teeth.  To  the  continuous  partial-clasp 
are  soldered  spring-wires  which  are  shaped  to  hook  over  the  edge  of  the  teeth  at 
the  junction  of  those  to  be  retained,  passing  on  to  the  labial  side  to  support  them. 

F.  A  suspension  plate  for  retaining  teeth  loosened  from  pyorrhoea  alveolaris 
and  holding  an  artificial  tooth.  It  is  made  similar  to  the  one  previously 
described. 


491 


PLATE    XXXVII 
Arch,  Expansion  of 

A.  A  vulcanite  palatine  plate  for  expanding  the  arch,  connected  with 
a  U-shaped  spring  and  anchored  with  wire-clasps. 

B.  A  plate  used  for  the  lateral  expansion  of  the  arch,  at  the  same  time 
rotating  the  central  incisors  inward  with  two  gold  springs  passing  to  the  labial 
side  of  the  teeth. 

C.  A  plate  for  the  lateral  expansion  of  the  anterior  part  of  the  arch.  The 
halves  of  the  plate  were  connected  with  a  simple  looped  spring-wire  located 
in  the  distal  part  where  the  arch  was  broad  enough. 

D.  An  appliance  used  for  the  unequal  expansion  of  the  arch  to  cause  room 
for  an  instanding  lateral  incisor. 

E.  A  divided  plate  connected  with  a  U-shaped  spring,  that  was  used  for 
expanding  laterally  the  anterior  part  of  the  lower  arch,  at  the  same  time  moving 
outward  instanding  incisors. 

F.  An  appliance  used  for  the  unilateral  expansion  of  the  arch.  The  plate 
was  anchored  to  the  teeth  not  to  be  moved.  The  other  side  of  the  arch  was 
forced  outward  by  a  long  S-shaped  spring  anchored  in  the  rubber,  the  other  end 
of  the  spring  being  attached  in  a  metal  anchorage  including  the  teeth  to  be 
moved. 


492 


Plate  XXXVII 


Plate  XXXVIII 


PLATE    XXXVIII 
Incisors,  to  move  Outward 

A.  A  palatine  plate  and  finger-spring  used  for  moving  incisors  outward.  It 
is  retained  by  spring-wires  extending  from  the  margin  of  the  plate  over  the  arch 
at  the  junction  of  the  teeth  reaching  towards  the  gum,  the  ends  resting  in  the 
interdental  spaces. 

B.  A  plate  retained  by  wire-clasps  passing  over  the  arch  to  rest  on  the 
buccal  side  of  the  molars. 

C.  A  vulcanite  plate  retained  with  wire-clasps.  A  finger-spring  is  attached 
in  the  front  part  to  move  incisors  outward. 

D.  A  palatine  plate  supporting  two  artificial  teeth,  and  a  finger-spring 
attached  in  the  anterior  part  for  moving  incisors  outward. 

E.  A  vulcanite  plate  with  two  looped  springs  attached  in  the  front  part  for 
forcing  lateral  incisors  outward.  The  free  ends  of  the  springs  pass  under  lugs 
on  collars  cemented  to  the  laterals. 

F.  A  cast-metal  plate  with  two  finger-springs  extending  from  the  anterior 
part,  used  for  moving  outward  instanding  incisors. 


493 


PLATE    XXXIX 

Incisors,  to  move  Inward 

A.  A  palatine  plate  anchored  by  wire-clasps.  A  semicircular  spring  passed 
over  the  arch  to  rest  on  the  labial  faces  of  prominent  incisors  for  moving  them 
invpard. 

B.  A  plate  with  two  finger-springs  for  moving  backward  prominent  cuspids, 
and  a  semicircular  spring  for  moving  inward  the  incisors. 

C.  A  palatine  plate  with  a  finger-spring  attached  on  each  side  to  extend  over 
the  arch  at  the  junction  of  the  teeth,  then  forward  to  rest  on  the  labial  faces  of 
the  teeth  to  be  moved.  The  ends  of  the  springs  are  left  long  to  pass  one  another 
at  the  median  line. 

D.  A  plate  with  springs  made  similar  to  the  one  last  described  for  moving 
inward  prominent  incisors  and  cuspids.     It  is  retained  by  wire-clasps. 

E.  A  rubber  plate  with  two  finger-springs.  Plate-metal  is  soldered  to  the 
wire-clasps  and  arranged  to  press  above  the  margin  of  the  gum  when  the  teeth 
are  not  fully  erupted. 

F.  A  palatine  plate  anchored  with  spring-clasps.  Two  finger-springs  are 
arranged  to  pass  over  the  arch  at  the  junction  of  two  of  the  teeth  that  are 
in  correct  position.  The  ends  of  the  springs  rest  on  prominent  teeth  that  are  to 
be  moved  inward. 


494 


Plate  XXXIX 


Plate  XL 


PLATE    XL 
Incisors,  to  move  Inward 

A.  A  palatine  plate  with  a  semicircular  spring  and  U-shaped  loops  for 
moving  inward  prominent  upper  incisors  and  cuspids.  Action  is  effected  by 
closing  the  loops  of  the  spring.  The  sides  of  the  plate  were  dressed  away  for 
the  regulation  of  the  bicuspids. 

B.  A  vulcanite  plate  for  moving  inward  the  six  front  teeth,  retained  by 
wire-clasps  around  two  of  the  molars  and  two  of  the  bicuspids. 

C.  A  plate  with  semicircular  spring  and  U-shaped  loops  arranged  for  moving 
inward  the  incisors.  Force  is  caused  by  bending  inward  the  front  portion  of  the 
spring,  twisting  the  wire  in  the  loops. 

D.  A  palatine  plate  with  a  semicircular  spring.  To  the  spring  is  attached  a 
curved  clip  to  pass  over  the  edge  of  the  incisors  to  prevent  the  spring  from 
slipping  towards  the  gum. 

E.  A  palatine  plate  with  a  semicircular  spring  for  correcting  incisors,  and 
two  curved  finger-springs  for  moving  cuspids  backward. 

F.  A  rubber  plate  and  semicircular  spring  for  moving  inward  prominent 
upper  incisors.  The  anterior  part  is  shaped  into  an  inclined  plane  for  depressing 
lower  incisors. 


495 


PLATE    XLI 
Incisors,  to   depress 

A.  A  vulcanite  palatine  plate  with  the  anterior  part  thickened,  forming 
an  inclined  plane  for  depressing  extruded  lower  incisors. 

B.  A  palatine  plate  and  inclined  plane  anchored  with  wire-clasps. 

C.  A  vulcanite  plate  and  inclined  plane  anchored  with  wire-clasps  and 
spring-clasps. 

D.  A  rubber  plate  with  an  inclined  plane  of  plate-metal  riveted  to  the 
anterior  portion. 

E.  A  plate  with  a  metal  inclined  plane  attached  by  rivets.  Additional 
layers  of  plate  metal  are  attached  when  necessary  by  soldering  carefully  with 
soft  solder,  using  a  soldering  iron. 

F.  A  palatine  plate  and  metal  inclined  plane  with  a  finger-spring  attached 
in  the  anterior  portion  for  evening  the  upper  incisors. 


496 


Plate  XLI 


Plate  XLII 


B 


PLATE    XLII 
Cuspids,  to  move   Outward,   and  In-ward 

A.  A  vulcanite  palatine  plate  with  a  finger-spring  used  for  moving  outward 
a  cuspid. 

B.  A  palatine  plate  with  a  spring,  employed  for  moving  inward  and  back- 
ward a  prominent  cuspid. 

C.  A  rubber  plate  with  two  looped  springs  for  moving  inward  prominent 
cuspids. 

D.  A  plate  with  an  inclined  plane  for  depressing  lower  incisors,  at  the 
same  time  moving  backward  and  inward  upper  bicuspids  and  prominent  cuspids. 

E.  A  palatine  plate  with  a  long  finger-spring  passing  over  the  arch  at  the 
junction  of  the  teeth  and  extending  forward  to  move  inward  and  backward 
a  prominent  cuspid. 

F.  A  vulcanite  plate  with  two  tinger-springs  arranged  for  moving  the 
bicuspids  backward  and  a  prominent  cuspid  inward  and  backward. 


497 


PLATE    XLIII 

Bicuspids,  to  move   Outward,  Inward,  Backward,  and 

Forward 

A.  A  palatine  plate  with  springs  attached  in  the  lateral  sides  of  the  distal 
part  projecting  forward  to  move  outward  bicuspids. 

B.  A  vulcanite  plate  with  a  spring  attached  in  the  anterior  part  projecting 
backward,  to  move  outward  a  bicuspid  and  a  molar,  at  the  same  time  the  incisors 
are  moved  inward  by  a  finger-spring. 

C.  A  palatine  plate  with  springs  attached  in  the  central  portion  projecting 
outward  for  moving  bicuspids  backward  or  forward.  It  also  has  a  semicircular 
spring  with  a  loop  for  evening  the  incisors. 

D.  A  plate  with  springs  attached  in  the  central  part,  projecting  outward  for 
moving  bicuspids  backward  in  the  line  of  the  arch.  Supplemental  force  was 
given  by  a  cross-bar. 

E.  A  rubber  plate  with  a  metal  inclined  plane,  and  springs  attached  in  the 
lateral  sides  for  moving  bicuspids  outward  and  forward. 

F.  A  plate  used  for  moving  inward  prominent  cuspids  and  evening  the 
bicuspids. 


498 


Plate  XI.III 


Plate  XLIV 


mm 


PLATE    XLIV 
Retaining 

A.  A  palatine  vulcanite  plate  for  retaining.      It  is  held  in  place  by  a  suction 
and  fitting  the  necks  of  the  teeth. 

B.  A  plate  fitting  the  necks  of  the  teeth  supported  by  wire-clasps  passing 
over  and  around  the  first  bicuspids. 

C.  A  palatine  plate  used  for  retaining  when  there  are   spaces  between  the 
bicuspids. 

D.  Shows  a  vulcanite  plate  used  for  retaining  when  there  are  broad  inter- 
dental spaces  between  the  bicuspids  and  molars. 

E.  A  retaining  plate  supported  by  wire-clasps  passing  around  the  second 
molars. 

F.  A  palatine  plate  with  a  semicircular  spring  and  U-shaped  loops,  anchored 
by  spring-clasps.      It  was  used  for  retaining  corrected  prominent  incisors. 


499 


INDEX 


Abrasion,  appliance  to  prevent,  202 
of  cuspids,  298 
of  incisors,  298 
of  molars,  208 
Acquired  constitutional  causes  of  irreg- 
ularities,  14 
Action  of  spring,  113 
Adenoid  growths,  25-28 
catarrh  from,  26 
character  of,  25 
characteristic      complications, 

26 
facial  expression  caused  by,  26 
obstructing  nasal  passage,  25 
secretion  from,  26 
symptoms  of,  26 
Age  for  jumping  bite,  339 
to  regulate,  68-70 

advantage  of  early  correction, 

68 
child,   69 

depi'ession  of  incisors,  293 
health   and   temperament,  69 
mature  patients,  70 
objection   to   early  correction, 
70 
Allan,  George  S.,  chin-cap,  326 

introduced   chin-cap,    102 
Alveolar  process,  17,  53,  54 

absorption   of,   54,   239 
removal  of,  for  retaining,  351 
in   lack  of  occlusion,  348 
in  regulating,  351 
structure,  function,  53 
Ammon,  canthoplasty,  449 
Anchorage,      affected     by     extraction, 
395 
and  appliances,  74-115 
base-wire.   80-84 

labio-buccal,    82 
lingual.  81 

palatal  or  palatine,  82 
chin-cap,  100 
clasp-benders,  78 


Anchorage,  collars  for,  88,  107,  212 

collar  with  tube  supporting  base- 
wire,   374 
continuous  partial-clasp,  78 
contouring  pliers,  77 
cross-bar,  98 

difficulty  in  cementing  collars,  107 
external,  90 

independent,  102 
supplemental,    102,   167 
fixed  point  of  resistance,  118 
for  moving  a  cuspid,  354 
for  rotating,  89 
gained  by  a  plate,  237 
improved  cross-bar,  99 
ligatures  for,  87 
metal  caps.  91 

over  molars  for,  329 
moving  cuspids  backward,  88,  93 

inward  six  teeth,  94 
objections  to  collars,  107 
partial-clasp,   76 
partial-clasps   used    independently, 

86 
plates,  93 
rigid  base-wire,  81 
spring  base-wire,  81 
spring-clasp,  78 

attachment.  76 
teeth  best  suited  for,  84 

elevated  by  rubber  bands,  337 
to  relieve  impaction,  90 
tubes  for,  88 

for  adjustment  of  springs,  87 
with  teeth  decayed,  86 

not  fully  erupted,  86 
wire-clasps,  87 
Angle,   E.   H.,   collars   bolted   to  teeth, 
116,   212 
equalizing  jaws.  337 
resection  of  lower  jaw.  332 
Anomalies,  45 

Anterior    expansion,    lower    arch,    144- 
146,  457 
upper  arch.   147-149,  459 
palatine  canal,  19 

501 


502 


INDEX 


Anterior       protrusion,       constitutional 

causes,  33 

local  causes,  33 

Antrum  of  Higlimore,  IS 

Apparent  double  protrusion,  253 

recession,  cause  of,  336 

lower  jaw,  336 
upper  protrusion,  338 
Appearance     marred     by      interdental 

spaces,  256 
Appliance,  desirable  location  of,  220 
fusible  metal,  to  make,  427 
for    bodily    movement    of    incisors, 

260 
for  closing  interdental  space,  307 
for  opening  bite,   199 
for  regulating,  used  for  retaining, 

233 
on  lower  teeth  moving  upper,  400 
retaining  teeth   loosened  by  pyor- 
rhoea, 437 
Appliances,  care  of,  during  regulation, 
119 
electro-plating,    103 
finishing  and  polishing,  112 
for  retention  of  teeth,  415-441 
holding  while  soldering.  111 
repairing  of,  113 
to  make,  74-112 
Application  of  force,  117 
Arch,  anterior  protrusion,  31 

backward  movement  of,  214 

chart  of,  30 

contraction  of,   150-155,  461 

from      lack     of      support     of 
tongue,  345 
expansion  of,  68,  121-149,  492 
anteriorly,    144-149,   314 
laterally,   123-138,   316 
unilaterally,   138-144,  460 
lower,  anterior  expansion,  144-146, 
457 
contraction  of,   150-152 
lateral  expansion  of,   123-129, 
456 
movements  in  expan.sion,  122 
norma]  and  abnormal,  31 
saddle-shape,  17,  34 
upper,    anterior    expansion,     147- 
149,  459 


Aich,    upper,    anterior    lateral    expan- 
sion,  131 
contraction  of,  152-155 
high  vault,  346 
lateral      expansion,      129—138, 
458 
V-shape,    17,   31 

to   regulate,   233 
Arches,  comparative  size  of,  56 
lack  of  harmony  of,  236 
to  equalize,  236 
Articulation  of  teeth,  55 

temporo-maxillary  changed,   338 
Artificial    tooth    to    close    interdental 

space,  306 
Attachment  of  springs,  104 
to  plates,  105 
with  solder.   111 
Attrition  of  incisors,  to  prevent,  298 
Auditory  canal,  18 

B 

Backward  movement  of  molars,  413 
Baker,  H.  A.,  equalizing  jaws,  337 

spur  retainer,  435 
Band.      (See  collars.) 
Bar,  labio-buccal,  418 
Bars,   long,   in  connection  with   plates, 
212 
to  move  incisors  outward,  211 
Base-wire,   80-83 

anchored  by  tube  on  collar,  374 

by   tubes   on   collars,   88 
arrangement  of,   104 
attachment  of  springs,  112 
flanges  attached  for  anchorage,  313 
forms  of,  81 
inclined    planes    attached   to,    366, 

370 
labio-buccal,  82 
lingual,  81,  214 

spurs  attached  for  anchorage, 
313 
location  of  in  anchorage,  124 
metals  for,  80 

moving  lower  incisors  inward,  214 
palatal  or  palatine,  82 
palatine  with  arms,  387 
plate  metal  attached,  225 


INDEX 


503 


Base-wire,  rigid,  81 

converted  to  spring,  83,  315 
spring,  81,  104 
to  locate,  215 
Bicuspids,    ancliorage    to    move    back- 
ward, 93 
backward  by  infralabial  bar,  403 
movement    of,     372,     395-403, 

487,  498 
supralabial  bar,  403 
depression  of,  409 
elevated,  to  retain,  434 
elevation  of,  304,  408-409 
extraction  of,  73 
forward     movement     of,     404-40G, 

487,  498 
impaction  to  relieve,  179,  188 
inward  movement  of,  391-394,  48G, 

498 
lower,  bodily  movement  backward, 
400 
moved  backward  by  cross-bar, 
402 
moved  backward  by  external  force, 
331 
by  U-shaped  spring,  367 
outward    movement     of,     382-390, 

485,  486,  498 
relieving    impaction    of,    406-408, 

487 
retention  of,  424,  434 
rotation  of,  291,  409 
second,    objections    to    extraction, 

247 
time  of  eruption  of,  30 
upper,  bodily  movement  backward, 
400 
moved  backward  by  cross-bar, 
399 
which  to  extract,  395 
Bite,  to  open  for  regulation,  141,  198- 
204,   331 
too   short,   causing  double   protru- 
sion,  199 
Bodily  movement  of  incisors,  306-323 
inward,   320-323 
laterally,    306-309 
outward,  310-320 
Bone,  intermaxillary,  19 

removal  of,  332,  348,  351 


Bone,  stretching  of,  310 
Bones,  mal development  of,  24 
nutrition  of,  14 
rhachitic,    17 
Box-shaped  attachment  on  collar,  275, 

300 
Bridge  removable  for  retaining,  436 
Brophy,  T.   W.,  cleft-palate  operation, 

450 
Buccinator  muscle,  23 

attachment     of,     to     alveolar 

process,  344 
in    chewing    hard    substances, 
23 
Byrnes,    B.    S.,    spring    plate-metal    in 
regulating,  210 


Canal,  anterior  palatine,  19 

Canine    eminence,    loss    by    extraction, 

375 
Canthoplasty,  449 
Cap,  cranial,  97 

to  make,  97 
metal,  301,   92,  322 
for  anchorage,  338 
for  retaining,  432 
hooks  of  wire  attached,  92 
horizontal   planes  on,   for  an- 
chorage, 314 
making,  92 

occlusal  planes  on,  338 
to  cement,   92,   311 
with  arms  attached,  310,  322 
with  eyelet  and  shoulders,  313 
with  eyelet  attached,  329 
with   eyelet,  on   incisors,  412 
with  lingual  base-wire,  412 
with  shoulder  or  trough,  432 
metals  for  making,  432 
tube  attached,  92 
Caps  for  anchorage,  91 
eyelets  for,  92 
metal  on  bicuspids,  402 
and  molars,  402 
Case,  C.  S.,  equalizing  jaws,  337 
moving  teeth  bodily,   323 
permanent  retainer,  435 
Catalan,   inclined   plane,   193,  211 


604 


INDEX 


Cementing  collars,  108 

metal  caps,  92 
Chart,  lines  of  movement  in  expansion, 
122 
movements  in  rotation,  264 
Charts  for  class-work,  66 
Chatellier,  adenoid  growths,  27 
Cheeks,  hollow,  plumper  for,  449 
Chin-cap,  100 

Allan,  George  S.,  326 
and  wire-standards,  page  167,  219 
depressing  incisors,  297 
elevating  incisors,  304 
for  reducing  prognathism,  330 
moving  incisors  bodily,  317 
best  age  to  apply,  328 
closing  the  lips,  416 
depressing  lower  incisors,   102 
force  with,  101 
how  to  shape,  327 
labial  spring  on,  167 
lack  of  anterior  occlusion,  344 
lines  of  force  with,  327 
making,  100 
materials  for,  101 

for  lining,  328 
number  of  hours  to  be  worn,  328 
reducing  prognathism,  325 
soreness  from,  328 
supported  by  cranial-cap,  102 

by  wire-standards,   102 
supporting  fractured  jaw,  168 
to  be  most  effective,  328 
use  of,  214 
Clasp-benders,  78 
Cleft-palate  and  harelip,  450 

first  operation  for,  450 
Coffin,   W.   H.,   expansion,   lower   arch, 
128 
method,   110 
upper  arch,  136 
modified  plate,  138 
plates  to  make,   110,   130 
Collar,  bar  on,  used  in  rotating,  269 
box-shaped     attachment     to,     170, 

275,   300 
cementing,  to  cuspid,  381 
curved  metal  attached,  371 
eyelet  on,  for  regulating,  221 
flange  attached,   431 


Collar,  flange  on,  for  rotating,  287 
hinge  attachment  to,  312 
hook  on,  to  hold  spring,  272 
loops  on,  to  anchor  spring,  271 
socket  on,  357 
spring    soldered    to,    for    rotating, 

272 
spur  on,  for  retaining,  429 

in  rotating,  276,  283 
T  attached,   287 
to  retain  with  a  screw,  270 
tube  attached,  for  retaining,  430 
holding  base-wire,  374 
lingual  side,  267 
tubes  attached,  412 
Collars,  arms  attached,  311 

bolted  to  teeth  for  holding  appa- 
ratus, 212 
cementing,  108 
difficulty  in  cementing,   107 
eyelets   on,   to   engage  with   cross- 
bar, 403 
for  anchorage,  88,  107,  212 
gold  crowns  used  in  place  of,  433 
history  of,  106 
hooks  on,  167 
lugs  attached,  109 
Magill  method  of  cementing,  264 
making,  107 

pins  and  eyelets  attached,  257 
supporting  bar  for  retaining,  433 
tubes   attached,   Evans,   Thos.   W., 
107,  264 
for    holding    long    bands, 
212 
attached  to,   109 
on,  for  anchorage,  419 
on,    for    anchoring    base-wire, 
88 
wire  lugs  to  attach,  373 
Continuous     partial-clasp,     adjustment 
of,  441 
making,  441 
retaining  incisors,  440 
spring-clasp,   78,   223 
Contouring  pliers,  77 
Contraction,  dental  arch,  150-155,  461 
lower  arch,  150-152 
upper  arch,  152-155 
I  Corning,  subcutaneous  treatment,  448 


INDEX 


505 


Cranial-cap,  97 

eyelets  attached  to,  167 
making,  97 
metal  band  on,  330 
plate-metal  attached  to  band,  1()7 
position  on  head.  97 
supporting  a  cross-bar,  230 
chin-cap,   1G7,  219,  330 
Cross-bar,  98 

depressing  incisors,  296 
improved,  99 

to  make,  99 
making,  98 
materials  for,  98 
moving  cuspids  backward,  371 

lower     incisors     inward,     325, 

330,  402 
teeth  bodily,  323 
upper  bicuspids  backward,  399 
upper  incisors   inward,   236 
use  of,  in  double  protrusion,  254 
in  lack  of  occlusion,  344,  347 
in  prognathism,  325,  332,334 
to  improve  occlusion,  317 
Crowns,  gold,  used  in  place  of  collars, 
433 
Richmond,   212 

use  of  in  lack  of  occlusion,  349 
Cuspid,  compensating  device   for  mov- 
ing, 354 
eruption  assisted  by  removing  gum, 

380 
extreme  force  for  moving,  353 
inward  movement  of,   185 
jack-screw  for  moving,  356 
to  broaden  space  for,  376 
Cuspids,  abrasion  of,  298 

anchorage    for    moving    backward, 

88 
backward   movement   of,    181,   362- 

379,  482-484 
deciduous,  time  of  eruption  of,  30 
depression  of,  381 
elevation  of,  304,  379-381 

Jackson,  H.  H.,  381 
eruption  of,  30,  351 
extracted    to    relieve    irregularity, 

206 
extraction  of,  73 
forward  movement  of.  351-361 


Cusjjids,  inward  movement  of,  362-379, 
480-483,  497 
lower,  supplemental  force  for  mov- 
ing backward,  372 
to  move  with  cross-bar,  371 
moved  by  external  force,  331 
outward,  incisors  inward,  359 

movement    of,    351-361,    478, 
497 
permanent,  time  of  eruption  of,  30 
preserving  space  for,  310 
rotation  of,  291,  381 
supplemental  force  to  move,  361 
upper,  supplemental   force  moving 
backward,  372 

D 

Deciduous   roots,   deflecting   permanent 
teeth,   220 
teeth,  regulated  by  inclined  plane, 
197 
regulation  of,  69 
Deflection  of  septum,  28-30 
Deformities,  influence  of.  Roe,  442 

treated  by  paraffin,  448 
Delavan,   D.   B.,   deflection   of   septum, 

28 
Dench,  E.  B.,  shaping  the  ears,  449 
Dentine,  wearing  away  of,  298 
Depressing  bar,  296 
Depression  of  bicuspids,  409 
of  cuspids,  381 
of  incisors,  292-297,  496 
of  molars,  414 
Development    of    premaxillary    encour- 
aged, 310 
Devices,  fixed,  for  retaining,  428-434 
permanent,  for  retaining,  434-441 
removable,  for  retaining,  417-428 
Disto-lingual  rotation  of  incisors,  282- 

291 
Double  protrusion,  398 

corrected  by  opening  bite,  199 
or  true  prognathism,  253 
thick  lips  in,  254 
treated  by  supralabial  and  in- 

fralabial  bar,  255 
use  of  cross-bar  in.  254 
rotation,  fixed  device  for,  276 


506 


INDEX 


Dressing  enamel  of  teeth,  299 
Dwinelle,    William,    author    of    jack- 
screw,  135 

E 

Ear,  artificial,  449 

deformity  of,  449 
Ears,  shaping  of,  by  bandage,  449 
Effects  of  muscular  action,  16 
Egenolff,  Chr.,  finger-pressure,  210 
Electro-plating  appliances,   103 
Elevation  of  bicuspids,  304,  408,  409 
of  cuspids,  304,  379-381 
of  incisors,  300-305 
of  lower  teeth,  305 
of  molars,  304,  414 
of  teeth,  objections  to,  303 
Enlarged   tonsils,    a   cause   of    progna- 
thism, 331 
Epicanthus,  449 
Equalizing  device,  330 

moving  lower  incisors  inward, 
214 
the  jaws,  336-338,  488 
Angle,  E.  H.,  337 
Baker,  H.  A.,  337 
Case,  C.  S.,  337 
how  brought  about,  338 
more      favorable      with      the 

young,  338 
result  sought  for,  338 
Eruption  of  teeth,  retarded,  300,  379, 
408 
time  of,  30 
Etiology,  13-52 

acquired  constitutional  causes,  14- 

39 
adenoid  growths,  25 
constitutional    and    local     factors, 

13 
effects  of  muscular  action,  16 
enlarged  tonsils,  24 
heredity,   13 

hypertrophy  of  the  tongue,  38 
infantile   scorbutus  and   rhachitis, 

15 
influence  of  muscles,  16 
inherited      constitutional      causes, 

13-14 
injurious  habits,  49 


Etiologj',  local  causes,  39-52 
mouth-breathing,   24 
neurotic  tendencies,  14 
normal  and  abnormal  arch,  31 
premature     extraction     deciduous 

teeth,   39 
prognathism,   35 
rhachitis,  14 
rhinitis,  25 
saddle-shaped  arch,  34 
scorbutus,   14 
scrofula,   14 

supernumerary  teeth,  43 
syphilis,  14 
too    long    retention    of    deciduous 

teeth,  43 
unwise    extraction    of    permanent 

teeth,  41 
V-shaped  arch,  31 
Eustachian  tube,  25 
Evans,  Thomas  W.,  collars  with  tubes, 
107,  264 
skeleton-cap  to  support  rigid  bar, 
107 
Examination  of  patients,  57-67 
history  of  case,  57 
physical  examination,   58 
record,  58 
Expansion,  anterior  lateral  upper  arch, 
131 
lower  arch,  144,  147 
upper  arch,  147-149 
chart  showing  lines  of  movement, 

122 
force  for,  124 
lateral,  lower  arch,   123-129,   164 

upper  arch,  129-138 
laterally  for  regulating,  214 
lower  arch,  extreme  case,   127 
of   lower    arch    causing    expansion 

of  upper,   163 
of  the  dental  arch,  121-149 
unilateral,  lower  arch,  123 
upper  arch,   138 
Expression,  importance  of  teeth  in,  220 
External  anchorage,  96 

for     moving     bicuspids    back-, 
ward,  372,  399-403 
cuspids,  361,  371 
Kingsley,  97 


INDEX 


507 


External  force  depressing  incisors,  296 
in  changing  lower  jaw,  328 
in    regulating    lower    incisors, 
167,  219,  255,  325,  330, 
403 
upper   incisors,   236,   237, 
253,  255,  330 
with     cross-bar,     moving     in- 
cisors bodily,  323 
independent  anchorage,   102 
supplemental  anchorage,   102 
Extraction,    bicuspids    to    cause   space, 
395 
for  regulating,  214 
injudicious,  177,  344,  375,  382 
necessity  of,  237 

premature,  of  deciduous  teeth,  39 
proper  time  for,  395 
too  early,  177 

to     relieve     irregularities,     71-75, 
237 
bicuspids,  73 
cuspids,   73,   206 
incisors,  72 
molars,  74 
unwise,  permanent  teeth,  41 
Extruded  incisors,  to  depress,  292-297 
Eye,   to  improve  expression  of,  449 
Eyelets,  attached  to  metal  caps,  92 
to  teeth,  440 
on  collars,  221,  403 
on  metal  caps,  402 
Eyelids,  plastic  operation  on,   449 


Face,  general  orthopsedia  of,  442^50 
model  of,  64 

shield  for  making,  65 
Facial    expression,    operation    on    eye- 
lids for,  449 
line,  336 
Farrar,  J.  N.,  collars  bolted  to  teeth, 
116,  212 
gold  filling  for  retaining,  435 
intermittent  pressure,   118 
lateral    bodily    movement    of    in- 
cisors. 309 
positive  system,  118 
Fay,  M.  L.,  elevation  of  teeth,  408 


Features,  before  and  after  correction, 
200,  236,  242,  253,  328,  330,  332, 
398-402 
changed  by  regulating  teeth,  236 
improved  by  injection  of  paraffin, 
448 
by  operation  on  nose,  448 
by  plate  and  teeth,  333 
improvement  of,   398-402 
in     double     protrusion     improved, 

253 
large,  avoid  extraction,  71 
marred  by  prominent  teeth,  237 
model  before  and  after  regulating, 

329 
prominent  cheek-bones,  42 
nose,  41 
Ferrule.      (See  collars.) 
Finger-pressure,  case  regulated  by,  260 
Egenolff,  210 
moving  bicuspid,  390 
Finishing  and  polishing  appliances,  112 
Fixed  retaining  devices,  428-434 
Flange  on  collar  for  rotating,  287 
Fleischmann,  shape  of  jaws  afl'ected  by 

muscles,  24 
Force,  application  of,  117 

applied  near  the  gum,  220 

chin-cap  for,   101,   331 

constant,  intermittent,  vacillating, 

118 
cross-bar  moving  bicuspids,   399 
expanding  arch,   124 
external,  with  cross-bar,  371 
how  applied  with  chin-cap,  327 
in  equalizing  the  jaws,  338 
infralabial   bar  for,   255 
in  regulation,  08 
moving  teeth   bodily,  321 
physiological  law,  118,  328 
supplemental,     elevating    incisors, 
304 
infralabial  bar  for,  215,  219 
moving  cuspids,  361 

incisors  bodily,  317 
lower      incisors      inward, 

215,   218 
molars  bodily,  413 
supralabial  bar  for,  237,  255 
Form  of  springs,   104 


508 


INDEX 


Forward  movement  of  molars,  411-413 
Fractured  jaw  supported  by  chin-eap, 

1G8 
Frsenum  labium,  abnormal,  259 

operation  on,  259 
Frankenberger,  adenoids  in  deaf-mutes, 

27 
Frog-nose,  446 


Gauge,    United    States    standard    wire. 

Brown  &  Sharpe,  74,  76 
General   orthopsedia   of   the   face,   442- 

450 
Gersuny,  paraffin  treatment  of  deformi- 
ties, 449 
Glands,  lymphatic,  25 

Waldeyer's  ring  of,  24 
Gleitsman,  J.  W.,  lymphatic  glands,  25 
Glenoid  fossae,  changes  in,  340 

from  force,  328 
Goddard,    C.    L.,    depressing    incisors, 
297 
cross-bar  device,  100 
elevating  device,  303 
Gold  and  silver  solder,  112 
Goniometer,  facial,  64 
Greene,  etiology,  16 

Guilford,    S.    H.,    fixed    inclined    plane, 
194 
retaining  devices,  430 
treatment  of  lack  of  occlusion,  348 
Gum  and  process  elevated  with   tooth, 
303 
congested,   to   treat,   239 
forced    back    by    sterilized    cotton, 

380 
incisors  impinging  against,  292 
separation  of,  from  neck  of  tooth, 

303 
slow  absorption  of,  239 

H 

Habits,  injurious,  49 
sucking  cheeks.  51 
fingers,  49 
or  biting  lips,  50 
thumb,  49,   253 
tongue,  51 


Harelip  and  cleft-palate,   450 
Haskins,  paraffin  prosthesis,  448 
Heath,  paraffin  treatment  of  nasal  sep- 
tum, 448 
Heredity,   13,   14 

general  law  of,  13 
peculiarities  of  the  features,  13 
race  characteristics,  13 
reproduction  of  peculiarities,  13 
transmission  of  characteristics,  13 
History,  earlj^  methods,  115 

later  methods,   116 
Hollow  cheeks,  plumper  for,  449 
Hooks  on  metal  caps,   92 
Hooper,  F.  H.,  adenoid  growths,  27 
How,  W.  S.,  shaping  the  teeth,  298 
Hullihen,  S.  P.,  resection  of  lower  jaw, 

332 
Hunt,  A.  0.,  making  masks,  64 


Impacted  molar,  to  relieve,  413 
Impaction,  anchorage  to  relieve,  90 
of  bicuspids,  to   relieve,   178,   188, 
406-408 
Impression  of  chin,  62 
Impressions,  58-02 
materials  for,  58 
method  of  taking,  59 
Improved  cross-bar,  99 
Improving   contour   by  use   of   crowns, 

212 
Incisors,  abrasion  of,  298 

accidental  fracture  of,  300,  302 
anchorage  to  move  inward,  94 
and  cuspids  inward,  214 

to  move  laterally,  263 
apparatus  for  lateral  bodily  move- 
ment of,  260 
appliance  for  rotating,  226 

to  prevent  abrasion,  202 
bodily  movement  of,  306-323 
Case,  323 
Farrar,  300 
outwaril,         sui)i)lotnontaI 

force  for,  318 
with  metal  cap,  322 
cementing  cap  to,  311 
crimping  of,  to  prevent,  326 
crowded,  to  correct,  176 


INDEX 


509 


Incisors,    deciduous,    regulated    by    in- 
clined plane,  197 

time  of  eruption  of,  30 
depressed,  to  retain,  424 
depression  of,  292-297,  496 

by  plate,  240,  397 

Goddard,  297 

metal  cap  for,  322 

plate  for,  292 

spring  for,  294 

supplemental  force,  297 

trough-shaped  device  for,  295 
disfigured  by  worn  edges,  331 
diverging  roots,  to  correct,  308 
double  rotation  of,  272 
edges  bevelled  for  retaining,  435 

worn  away,   169 
elevation  of,  300-305 

extreme  force  required,  305 

supplemental  force,  304 
extraction  of,  72 
extrusion  of,  338 
evened  by  use  of  plate,  246 
fractured,   227 
impaction  of,  300 
impinging  on  gum,  292 
influence  of  lower  on  upper,  220 
Inward,  bodily  movement  of,  320- 
323 

cross-bar  in  regulating,  236 

inclined  plane,  218 

lower,      supplemental      force, 

167,  218 

movement    of,    214-255,    469- 

473,  494,  495 
or  lingual  movement  of,  214- 

255 
supralabial  bar,  237 
irregularity    caused   by   pyorrhoea, 

228 
lateral   bodily   movement  of,   306- 
309 
expansion    for    inward    move- 
ment of,  214 
movement  of,  256-263,  477 
Jackson,  W.  H.,  257 
lower,   inward  movement  of,   214- 
220,  469 
outward    movement    of,    157- 

168,  462,  463 


Incisors,  luxation  of,  305 

moved    inward    and    cuspids    out- 
ward, 232 
bicuspids  outward,  389 
outward  by  long  bars,  211 
not  lapping  properly,  168 
occluding  on  edge,  to  correct,  331 
occlusion  changed  by  abrasion,  169 
outward  bodily  movement  of,  310- 
320 
getting  space  for,  160 
movement    of,    156-213,    462- 
408,   493 
encouraging   development, 
156 
to  prevent  wearing,  169 
permanent,  time  of  eruption  of,  30 
prominent  from  lower  lip,  220 
regulation  of,  156-323 

by  finger-pressure,  260 
with  T-device,  229 
reshaping,  297-299 
resting  edge  to  edge,  169 
retained  bj^  reshaping,  299 
retaining,  when  loosened  by  pyor- 
rhoea,  191 
retention  of,  418 
by  lap,   179 
rotation  of,  204-291,  474-476 
chart  of  movements,   264 
lingual  device  for,  267 
mesio-labially      or      disto-lin- 

gually,  282-291 
mesio-lingually    or    disto-labi- 

ally,  265-282 
objections   to   use   of   straight 
spring,  266 
tardy  eruption  of,  300 
too  rapid  movement  of,  256 
to  stay  attrition  of,  298 
upper  and  lower,  to  move  inward, 
253-255 
natural  position  of,  220 
to  move  inward,  220-255,  470- 

473 
to     move     outward,     168-213, 
464-468 
bodily,  408 
worn  by  false  occlusion,  189 
Inclined  plane,  193-198 


510 


INDEX 


Inclined  plane.  Catalan,  115 
fixed,  194 

Guilford,  194 
for  depressing  lower  incisors, 

•292 
history  of,  193 
jumping  bite,  341 

backward,  343 
moving  lower  incisors  inward, 

218 
objections  to,  195 
on  collar,  341 
removable,  194 
used  for  child,  197 
used  in  prognathism,  335 
when  to  use,  195 
planes  attached  to  base-wire,  366- 
370 
metal,  341 
Infantile  scorbutus,  15 

symptoms  of,  15 
Infralabial  bar,  168,  219 

moving    bicuspids     backward, 
403 
lower      incisors      inward, 
215,  330 
to  make,  219 
to  support,  255 
use  of,  255 
Injurious  habits.     (See  Habits.) 
Interdental  spaces,  closed  with  appara- 
tus, 250,  307 
with  artificial  tooth.  306 
interfering     with     pronuncia- 
tion, 256 
Interlocked  molar,  to  relieve,  413 
Intermaxillary  bone,  19 

stretching  of,  310 
Irregularity,  accompanied  with  mouth- 
breathing,   235 
acquired  constitutional  causes,  14 
age  to  correct,  68 
caused    by    deciduous    roots,    220, 
382 
by  accident,  47 
by  position  of  lower  lip,  220 
by  pyorrhoea,  51,  228 
by  supernumerary  teeth,  44 
etiology  of,  13-52 
extraction  to  relieve,  71-75,  237 


Irregularity,   fan-shape,   309 

from  injudicious  extraction,  382 
local  causes  of,  39-52 


Jack-screw    anchored    by    spring-clasp 
attachments,  356 
expansion  of  arch,   135 
Jackson,   H.   H.,   device  elevating  cus- 
pid, 381 
W.   H.,   moving  incisors  laterally, 
257 
Jaw,  apparent  recession  of,  336 
backward  movement  of,  214 
fractured,    supported   by   chin-cap, 

168 
hereditary    prominence    of    lower, 
331 
recession  of,  336 
lower,  development  of,  328,  339 

receding,  336 
prominent   lower,   to   reduce,   324r- 

335 
protrusion,     caused     by     wear     of 

teeth,  331 
resection  of.  Angle,  332 
Hullihen,    332 
Ottolengui,   332 
Whipple,  332 
to  change  angle  of,  328 
Jaws,  appliance  for  harmonizing  later- 
ally,  132 
approximation  of,  348 
equalized  by  rubber  bands,  337 
equalizing,  331,  336-338,  340,  488 
forcing     together     with     chin-cap, 

345 
inharmonious  relations  of,  340 
shape  of,  affected  by  muscles,  24 
Jewellers'  soft  solder,  110 
Jumping  the  bite,  338-343 
age  for,  339 
backward,  342-343 
forward,  340-342 
how  accompli. shed,  339 
Kingsley,  339 
object  of,  340 

to    retain    teeth    by    dressing, 
299 


INDEX 


511 


K 

Kingsley,  N.  W.,  artificial  ear,  449 
lip,  44'J 
nose,  449 
etiology,  14 
external  anchorage,  97 
jumping  the  bite,  339 
long  bar,  212 
lower  expansion,  128 
obturators  for  cleft-palate.  449 
Knapp,  operation  on  eyelid,  449 
Knobs,  adjustable,  304 

on  standards,  1G7,  255 
on  infralabial  bar,  219 


Labial  spring,  moving  forward,  cuspids, 
bicuspids,  molars,   168 
on  chin-cap,  1G7 
Labio-buccal  bar,  418 

with  loop,  418 
Lack  of  anterior  occlusion,  344-348 
extreme  case  of,  345 
to    treat    with    chin-cap, 
345 
of  lateral  occlusion,  349-350 

cause  of,  350 
of  occlusion,  344-350 

caused  by  injudicious  extrac- 
tion,  344 
by  thumb-sucking,  344 
chin-cap  to  correct,  347 
corrected  by  crowns,  349 
extraction    of    molars    to    cor- 
rect, 346 
from  change  of  lower  jaw,  34 1 

of  upper  jaw,  344 
grinding  of  molars  to  correct, 

346 
interfering    with    enunciation, 

345 
result  of  treatment,  347 
of  posterior  occlusion,  348-349 
Lateral    bodily    movement   of   incisors, 
260,  306-309 
expansion  of  lower  arch,   123-129, 
456 
of  upper  arch,  129-138,  458 
movement    of     incisors,     256-263, 
477 


Le  Mounier,  first  cleft-palate  operation, 

450 
Ligature,   115 

for  anchorage,  87 

for  holding  springs,  175 

for  retaining  teeth,  257 

moving  bicuspids,  394 

of  rubber  tubing,  212 
Lingual  movement  of  incisors,  214-255 
Lip,  artificial,  Kingsley,  449 

upper,  sunken,  375 
Lijjs,  closed  by  chin-cap,  416 

difficult  closure  of,  345 

drawn  by  irregularity  of  teeth,  237 

relative  position  of  teeth,  220 

thickened,    causing    apparent    pro- 
trusion, 253 
Local  causes  of  irregularities,  39-52 

of  protrusion,  33 
Long  band,  115 
Looped  spring  device,  227 
Lower    incisors    inward,    supplemental 
force,  218 
to  move  inward,  214-220,  469 
Lugs,  forms  of,    110 

to  make,  109 
Luschka's  tonsil,  24 


M 

Magill,  W.  E..  cementing  collars,  107 

method  of  cementing  collars,  264 
Malar  process,  19 
Mastication  improved  by  plate,  333 
Mastoid  process,  18 
Maxilla,  upper,  19 
Mayer,  Emil,  adenoids,  diagnosis  of,  27 

sinuses,  order  of  appearance,  18 
Median  line,  deviation  from,  376 
Mesio-labial  rotation  of  incisors,  282- 

291 
Metal  caps,  for  anchorage,  91 
to  cement,  92 

plates,  116 

for  retaining,  424 
Metallic  form  for  shaping  nose,  447 
Methods,  early,  115 

later,  116 
Meyer,   J.    H.,    plate    covering   natural 
teeth,  332 


512 


INDEX 


Meyer,  Wilhelm,  adenoid  vegetations,  2G 
Model  of  face,  64 

shield  for  making,  65 
Models,  carving,  for  wire-elasps,  238 
coloring  and  mounting,  62 
preparing  and  carving,  62 
jMolar.   deciduous,   broader   than  bicus- 
pid. 382 
impacted  to  relieve,  413 
importance  of  first,  74 
Molars,  abrasion  of,  298 

backward  movement  of,  413,  488 
deciduous,  time  of  eruption  of,  30 
depression  of,  345,  414 

to  permit  lips  to  close,  345 
device  to  move  bodily,  412 
elevated  by  buccinator  muscle,  344 
elevation  of,  304,  414 
extraction  of,  74 

in  lack  of  occlusion,  346 
first,  mistake  to  extract,  42 

unwise  extraction  of,  42 
forward  movement  of,  411-413,  488 
grinding   of,    in   lack   of   occlusion. 

346 
inward  movement  of,  411,  488 
natural  forward  movement  of.  247 
outward  movement  of,  410,  488 
permanent,    time    of    eruption    of, 
30 
unwise  extraction  of,  42 
regulation  of,  410-414 
removal   of,    in   lack   of   occlusion, 

348 
tendency  to  move  forward,  396 
Mouth-breathing,  21 
cases  of,  242,  243 
causing  lack  of  occlusion,  344 
Movements  of  teeth,  118,  264 
Moving  root  for  crowning,  213 
Mummery,  J.  H.,  etiology,  14 

excessive  mental  activity,  15 
premature  mental  exertion,  15 
Muscle,  buccinator,  17 

attachment     of,     to     alveolar 
process,  344 
Muscles,  head.  neck,  face,  22 
healthy  tonicity  of,  23 
influence  shape  of  arch,  23,  24 
masseter,  17 


Muscles,  natural  tension  of,  23 

orbicularis  oris,  21 
Muscular  action,  effects  of,  16 

N 

Nares,  constriction  of,  17 
Nasal    deformities.    Roe,    classification 
of,  443 
correcting,  442-448 
importance  of  correction,  442 
stenosis,  cases  with,  242,  243 
cause  of  prognathism,  331 
Niles,  E.  S.,  link  retainer,  435 
Normal  and  abnormal  dental  arch,  31 
Nose,  alse,  unequal  growth  of,  446 
artificial,  449 
cartilage  of,  443,  446 
collapsed  condition  of,  447 
concave  deformity,  445 
convex  vertical  deformity,  444 
correction     by     plastic     operation, 

242-248 
deflection  of,  446 
deformity  treated  by  paraffin,  448 
diseases  of,  17 
expansion  of  wings  of,  447 
flattening  of  dorsum,  445 
frog-nose,  446 

impediment  to  free  breathing,  24 
influence  of  heredity,  13 
metallic  form  for  shaping,  447 
orthopsedia  of,  442-448 
prominence  of,  considered,  320 
retrouse,  442 
saddle-back,  445 
septum  deflected,   17 
shaping  after  operation,  447 
size  of,  considered,  336 
snub-,   or    pug-nose,   446 
spatulated  deformity  of,  445 
too   prominent,  due  to  extraction, 
42 

o 

Obturators,  Kingsley,  450 
Occlusion,  55,  56 

accepted  type,  55 

changed    by    abrasion    of    the    in- 
cisors, 169 

false,  incisors  worn  by,  189 


INDEX 


613 


Occlusion,  improved  by  chin-cap,  317 
by  plate,  333 
lack  of,  344-350 

anterior,  344-348 
lateral,  349-350 
posterior,  348-349 
normal,  55 
to  improve,  336,  338 
Opening  the  bite,  198-204,  331 

in  unilateral  expansion.  141 
lower  incisors  inward,  217 
older  methods,  199 
Operations,  plastic,  on  nose.  Roe,  442- 

448 
Orbicularis  oris,  muscle,  21,  23 
Orbital  ridge,  18 

Orthopffidia,   features  before  and   after 
correction,  242 
clianged   by   regulating   teeth, 
200,  230,  253,  328,  330,  332, 
398-402 
improved  by  plate  and  teeth, 
333 
general,  of  the  face,  442-450 
Ottolengui,  R.,  resection  of  lower  jaw, 
332 


Palate  process,  19 
Paraffin,  method  of  injecting,  448 
treatment,  dangers  from,  448 
features  improved  by,  448 
for  deformities,  448 
Partial-clasp,  70 
continuous,  78 

retaining  incisors,  440 
metals  for,  76 

used  independently  for  anchorage, 
86 
Patrick,   J.   R.,    collars    with   bolt    and 

nut,  116 
Pericementum,     inflammation      of,     re- 
lieved by  opening  bite,  199,  201 
Peridental  membrane,   53 

thickened  by  insecure  devices, 
415 
Physiological  law  governing  force,  118, 

328 
Plastic  operations  on  nose,   Roe,   442- 
448 


Plate,  advantages  of,  in  regulating,  237 
assistance  of,  in  anchorage,  237 
bodily  movement  of  incisors,  311 
Coilin,  to  make,  116 

modified,  96 
divided  moving  incisors,  205 
dressing  of,  to  permit  movement  of 

teeth,  239 
metal  for  regulating,  116 
for  retaining,  424 
points    projecting    for    retain- 
ing, 424 
screws  in,  203 
moving  cuspid,  377 
moving  inward  six  teeth,  94 

upper  bicuspids  backward,  399 
objections  to  its  use,  237 
palatine  for  opening  bite,  333 

for  retaining,  428 
separated  laterally,  319 
skeleton  for  retaining,  428 
split,  connected  with  spring,  252 
spring  hinged   to,   241 
suspension  for  retaining,  438 
thickened  for  retaining,  433 
to  retain,  238 
with  inclined  planes,  341 
with   looped   spring   for    retaining, 

421 
with      semicircular      spring      and 

loops,  240 
with  springs  for  rotating,  290 

to  retain  incisors,  241 
with  two  finger-springs,  238 
Plates  for  anchorage,  93-96 
springs  to  attach,  105 
to  electro-plate  springs  of,  103 
with   long   bands    and    screw-nuts, 
212 
Pliers,   contouring,  77 

use  of  flat-nosed,  227 
Plumper,  to  make,  449 
Premaxillary  bone,  stretching  of,  310 

to  change  shape  of,  310 
Profile  records,  63,  64 
goniometer,  64 
profilometer,  63 
Prognathism,  35,   38,   324-335 

accompanied    with    nasal    stenosis, 
331 


33 


514 


INDEX 


Prognathism,  acquired,  3(5 

apparent,    relieved   by   moving   in- 
cisors, 188 
case  of  progressive,  202 
causes  of,  335 

caused  by  abnormal  occlusion,  Sol 
acquired  or  local  causes,   334 
enlarged  tonsils,  331,  334 
nasal  obstructions,  334 
too  close  bite,  333 
chin-cap  for,  100 
corrected  by  chin-cap,  335 
extreme  case  of,  318,  332 
heredity  of,  35 
inherited,  334 
local  causes  of,  38 
necessity  for  early  treatment,  332 
or  double  protrusion,  253' 
supplemental  force  for,  330 
to  treat  surgically,  332 
unilateral,  335 
Pronunciation,  appliance  arranged  not 
to  interfere  with,  130 
interfered     with     by     interdental 

spaces,  256 
to  correct  interference  with,  130 
Protrusion,  apparent  upper,  338 
double,  apparent,  253 

corrected  by  opening  bite,  199 
extreme  ease  of,  398 
lower,  correction  of,  214-219,  324- 

335 

upper,  correction  of.  235-255 

extreme  case  of,  248 

typical  cases  of,  242 

Pterygoid  process  of  sphenoid  bone,  18 

Pug-nose,  446 

Q 

Quinlan,   method   of  injecting  paraffin, 
448 
paraffin   treatment  of   deformities, 
448 

R 

Receding  lower  jaw,  336-343 

cause  of,  339 
Record  of  cases,  58 
Records,  profile,  63 
Regulating  bicuspids.  382-409 

care  of  teeth  and  appliances,  119 


Regulating,  continuous  force  for,  68 
crowns  to  improve  contour,  212 
cusjDids,  351-381 
deciduous  teeth,  69 
for  child,  inclined  plane,  197 
incisors,   156-323 
molars,  410-414 
spring-wire    anchored     in     fillings, 

176 
wedges  used  for,  212 
Relieving  impaction  of  bicuspids,  406- 

408 
Removable  bridge  for  retaining,  436 

retaining  devices,  417-428 
Repairing  appliances,  113 
Resume,  advantages  of  system,  114 
Retaining,  bar  supported  by  cemented 
collars,  433 
device,  collar  with  flange  attached, 

431 
devices,  415-441,  488-491,  499 
essentials  of,  415 
excessive  force  of,  415 
fixed;  428-434 
permanent,  434-441 
removable,  417-428 
incisors,  edges  bevelled  for,  435 
length  of  time  for,  280,  310,  317, 

415-417 
metal  caps  for,  432 
plates,  metal,  424 
rubber,  423,  428 
with  metal  points,  424 
removable  bridge  for,  436 
removal  of  alveolar  process  for,  351 
round  wire  preferable  for,  423 
space  for  erupting  cuspid,  431 
teeth  affected  by  pyorrhoea,  431 
wire  device  for,  424 
Retention  of  incisors  by  lap,  179 
of  the  teeth,  415-441 

application  of  chin-cap,  416 
cast  metal  appliance  for,  426 
in  case  of  heredity,  416 
in    cases    of   mouth-breathing, 

416 
object  of,  415 
Rhachitis,  15-23 

symptoms  of,  15 
Rhinitis,  25 


INDEX 


515 


Rhinological  operation,  243,  347 
Rice,  C.  C,  mouth-breathing,  24 
Richardson,  retaining  appliance,  426 
Roberts,  F.  T.,  etiology,  15,  l(j 
Robertson,  deflection  of  septum,  29 
Roe,  J.  O.,  correction  of  nasal  deformi- 
ties, 442-448 
Roots,  deciduous,  cause  of  irregularity, 
382 
deflecting      permanent      teeth, 
220 
moved  bodily,  306-323 
for  crowning,  213 
spring  to  move,  for  crowning,  213 
Rotating,  anchorage  for,  89 

appliance  suitable  for,  174 
box-shaped    attachment    on    collar 

for,  275 
plate  with  springs  for,  241 
Rotation  of  bicuspids,  291,  409 
chart  of  movements  in,  264 
of  cuspids,  291,  381 
of  incisors,  264-291,  474-476 

mesio-labially      or      disto-lin- 

gually,  282-291 
mesio-lingually    or    disto-labi- 
ally,  265-282 
Rubber  bands,  equalizing  the  jaws,  337 
moving  bicuspids,  393 
objections  to  use  of,  337 
in  place  of  base-wire,  218 
plates  and  inclined  planes,  116 
umbrella  rings  used  with  cross-bar, 

345 
vulcanite,  introduction  of,  212 


Scorbutus,  14 

Scrofula,   14 

Septum,  deflection  of,  cause  of  nasal  ob- 
struction, 28 

Shaping  the  teeth,  297-299 
How,  W.  S.,  298 

Siegfried,  spring  for  regulating,  213 

Sigmund,   moving  incisors  by   inclined 
plane,  211 

Silleto.  moving  root  for  crowning,  213 

Sinuses,  ethmoidal,   18 
frontal,  18 


Sinuses,  maxillary,  18 

sphenoidal,  18 
Skiagraph,  diagnosis,  record,  58 
Skull,  anterior  region  of,  20 
base  of,  19 
human,  16 

malar  bone  removed,  18 
Smith,  Eugene  H.,  screw  device,  210 
Smith    paraflin    treatment   of   deformi- 
ties, 448 
Solder,  gold  and  silver,  112 
soft,  grades  of,  110 
kinds  of,  110 
Soldering  appliances,  110-112 
essentials  in,  110 
flux  for,  111 
iron,  111 

to  heat.  111 
Solis-Cohen,  J.,  exostosis  of  hard  pal- 
ate, 33 
Spheno-maxillary  fissure,  18 
Sphenoid,  pterygoid  process  of,  18 
Spring,  action  of,  113 

anchored  in  fillings,  176 
base- wire,  104 
clasp,  78 

metals  for,  79 
attachment,  74-80 
continuous  spring-clasp,  223 
double-looped,  398 

moving  cuspid  backward,  367 
extending  over  arch,  223 
held  by  ratchet,  398 
labial  on  chin-cap,  167 
labio-buccal,  329,  393 
passing  over  the  arch,  236 
semi-circular  with  U-shaped  loops, 

240 
supported    by    box-shaped    attach- 
ment,  275 
to  harmonize  length  of  teeth,  273 
to    retain    in   box-shaped    opening, 

283 
U-shaped,  moving  bicuspids  back- 
ward, 367 
with  arms.  222.  392 
with  loops,  action  of.  217 
Springs,  adjustable  in  tubes,  87 
to  lengthen,   165 
advantage  of,  in  regulating,  118 


516 


INDEX 


Springs,  advantage  of  round  form,  103, 
239 
attached  in  plates,  208 
attachment  of,  104 
to  plates,  105 
end  flattened  to  retain  in  plate,  94, 

239 
extending  over  arch,  215 
finger,    moving    incisors    outward, 

159 
form  of,  104 

holding,  in  making  plates,  209 
increasing  space,  222 
in  plate,  advantages  of,  237 
location  of,  for  regulating,  238 
metals  for,  102 

preventing  injury  in  soldering,  110 
slipping  in  tubes,  273 
towards  gum,  239 
size  of.  103 

soldered  to  collar  for  rotating.  272 
stiffness  of,  239 

U-shaped     loop,     moving     incisors 
outward,   157 
loops,  216 
Spur  attached  to  collar  in  rotating,  265 
on  collar  in  rotating,  283 
to   prevent   outward  movement  of 
incisor,  274 
Spurs  on  lingual  base-wire,  313 
Staphylorrhaphy,  450 
Supernumerary  teeth,  43 

tooth  causing   torsion   of   incisors, 
289 
Supplemental    force,   depression   of    in- 
cisors, 297 
elevation  of  incisors,  304 
for  prognathism,  330 
infralabial  bar,  215 
moving  cuspids,  361 

incisors  bodily,  317 
lower      incisors      inward, 

167,  215,  218 
molars  bodily,  413 
supralabial    bar,   237 
with  a  cross-bar,  236 
Supralabial   bar,   attachment  to   teeth. 
318 
change  line  of  traction  of,  237 
making,  237,  255 


Supralabial      bar,      moving      bicuspids 
backward,    403 
incisors  outward,  331 

bodily,  318 
upper      incisors      inward, 
237 
to  support,  255 
use  of,  255 
Suspender  and  elastic  band,  219 
Suspension  plate  for  retaining,  438 
Swaging  metal  caps,  92 
Syphilis,  constitutional,  14 


T-deviee  for  regulating,  229 

for  retaining,  420 
Teeth  affected  by  pyorrhoea,  to  regulate, 
228 
to  retain,  437 
anomalies  of,  45 
arrested  development  of,  17 
attachment  of  eyelets  to,  440 
best  suited  for  anchorage,  84 
bodily  movement  of,  306-323 
care  of,  119-120 
checking  development,  17 
crimping  of,   338 

to  prevent,  216,  326 
decayed,  vitilized  for  anchorage,  86 
deciduous,  best  suited  for  anchor- 
age, 84 
premature  extraction  of,  39 
too  long  retention  of,  42 
deficient  calcific  deposit,  17 
depression    of,   292-297,   381,   409, 
414 
by  chin-cap,  416 
elevation     of,     300-305,     379-381, 

408,  409,  414 
extrusion  of,  292 
grinding  of,  to  improve  occlusion, 

348 
importance  in  expression,  220 
lateral  movement  of,  256-263,  275, 

306-309 
length  of  time  to  retain.  415-417 
lessoned  nutritive  supply,   17 
loosened   by   pyorrhoea,    to   retain, 
437-441 


INDEX 


517 


Teetli,  movoment  of,  with  process,  220 
movements  of,  118 
not  fully  erupted  utilized  for  an- 

cliorage,  8G 
permanent,  best  suited  for  anchor- 
age, 84 
regulation  of  bicuspids,  382-409 
cuspids,   351-381 
incisors,  156-323 
molars,   410-414 
retention  of,  415-441 
rotation  of,  264-291,  381,  409 
separation  of,  257 
shaping  of,  297-299 
supernumerary,  43 
time  of  eruption  of,  30 
too  rapid  movement  objectionable, 

308 
to  reshape,  297-299 
unwise    extraction    of    permanent, 
41 
Thumb-sucking,  49 

a  cause  of  upper  protrusion,  253 
to  correct,  253 
Tomes,  John,  blocks  of  ivory  in  regu- 
lating, 211 
moving    teeth    by    finger-pressure, 
259 
Tongue,  hypertrophy  of,  38 
normal  position  of,  19,  21 
position    of,    in    mouth-breathing, 
344 
Tonsil,  hypertrophy  of,  24 
lingual,  24 
Luschka's,  24 
pharyngeal,  24 
Tonsils,  chronic  enlargement  of,  24 

faucial,  24 
Torsion  caused  by  supernumerary  tooth, 

289 
True  prognathism  or  double  protrusion, 

253-255 
Tube  with  hole  through  the  sides,  274 
with  notch  for  holding  spring,  275 
Tubes  for  adjustment  of  springs,  87 
for  anchorage,  88 
making,  109 
metals  for,  109 


Tubes  on  collars,   157,  169 
on  metal  caps,  92 
position  on  collars,  88 

u 

Unilateral  expansion,  460 
opening  bite,  141 
upper  arch,  138 
prognathism,  140,  335 
causes  of,  335 
Upper  incisors,  inward  movement,  220- 
255,  470-473 
outward    movement,    108-213, 
464-468 
protrusion,  caused  by  thumb-suck- 
ing, 253 
extreme  case  of,  248 
treatment  of,  242 


Vela,  artificial,  Kingsley,  450 
Virchow,  rhachitis,  23 
V-shaped  arch,  31-33 

to  regulate,  233 
Vulcanite  in  place  of  base-wire,  218 
rubber,  introduction  of,  212 

w 

Waldeyer's  ring  of  glands,  24 
Wedges  for  regulating,  212 
Wedging,  117 

materials  for,  117 
to  move  bicuspids,  396 
Whipple,    J.    W.,    resection    of    lower 

jaw,  332 
Willis,    F.    M.,    lack    of    lateral    occlu- 
sion, 349 
Wire-clasp,  projecting  under  the  gum, 
238 
to  carve  model  for,  238 
Wire-clasps  for  anchorage,  87 
Wisdom-teeth  used  for  anchorage,  214 


Ziem,  nasal  stenosis,  30 
Zygomatic  arch,  18 

outer  border  of,  16 


THE    END 


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